Suicide methods

Suicide
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Organizations Compassion & Choices Death with Dignity National Center Dignitas Exit International Final Exit Network Hemlock Society

A suicide method is any means by which a person completes suicide, purposely ending their life.

Bleeding

Suicide by exsanguination involves reducing the volume and pressure of the blood to below critical levels by inducing massive blood loss. It is usually the result of damage inflicted on arteries. The carotid, radial, ulnar or femoral arteries may be targeted. Death may occur directly as a result of the desanguination of the body or via hypovolemia, wherein the blood volume in the circulatory system becomes too low and results in the body shutting down.

Juliet: O happy dagger! [Takes Romeo's dagger.] This is thy sheath. [Stabs herself.] There rust, and let me die. [Falls on Romeo's body and dies.]

– Romeo and Juliet, Act V, Scene III

Persons considering a suicide attempt, or trying out the weapon to ascertain its effectiveness, may first make shallow cuts, referred to as hesitation wounds or tentative wounds in the literature. They are often non-lethal, multiple parallel cuts.^[1]

Wrist cutting

Wrist cutting is sometimes practiced with the goal of self-harm and not suicide; however, if the bleeding is copious or allowed to continue unchecked, cardiac arrhythmia, followed by severe hypovolemia, shock, circulatory collapse or cardiac arrest, and death may ensue, in that order.^[2]

In the case of a failed suicide attempt, the person may experience injury of the tendons of the extrinsic flexor muscles, or the ulnar and median nerves which control the muscles of the hand, both of which can result in temporary or permanent reduction in the victim's sensory or motor ability or also cause chronic somatic or autonomic pain.^[3] As in any class IV hemorrhage, aggressive resuscitation is required to prevent death of the patient; standard emergency bleeding control applies for pre-hospital treatment.

Drowning

Suicide by drowning is the act of deliberately submerging oneself in water or other liquid to prevent breathing and deprive the brain of oxygen. Due to the body's natural tendency to come up for air, drowning attempts often involve the use of a heavy object to overcome this reflex. As the level of carbon dioxide in the victim's blood rises, the central nervous system sends the respiratory muscles an involuntary signal to contract, and the person breathes in water. Death usually occurs as the level of oxygen becomes too low to sustain the brain cells. It is among the least common methods of suicide, typically accounting for less than 2% of all reported suicides in the United States.^[4]

Suffocation

Suicide by suffocation is the act of inhibiting one's ability to breathe or limiting oxygen uptake while breathing, causing hypoxia and eventually asphyxia. This may involve an exit bag (a plastic bag fixed over the head) or confinement in an enclosed space without oxygen. These attempts involve using depressants to make the user pass out due to the oxygen deprivation before the instinctive panic and the urge to escape due to the hypercapnic alarm response. It is impossible for someone to commit suicide by simply holding their breath, as the level of oxygen in the blood becomes too low, the brain sends an involuntary reflex, and the person breathes in as the respiratory muscles contract. Even if one is able to overcome this response to the point of becoming unconscious, in this condition, it's no longer possible to control breathing, and a normal rhythm is reestablished.^[5]

Because of this, one is more likely to commit suicide through gas inhalation than attempting to prevent breathing all together. Inert gases such as helium, nitrogen, and argon, or toxic gases such as carbon monoxide are commonly used in suicides by suffocation due to their ability to quickly render a person unconscious, and may cause death within minutes.^[6][7]

Hypothermia

Suicide by hypothermia or by cold, is a slow death that goes through several stages. Hypothermia begins with mild symptoms, gradually leading to moderate and severe penalties. This may involve shivering, delirium, hallucinations, lack of coordination, sensations of warmth, then finally death. One's organs cease to function, though clinical brain death can be delayed.

Electrocution

Suicide by electrocution involves using a lethal electric shock to kill oneself. This causes arrhythmias of the heart, meaning that the heart does not contract in synchrony between the different chambers, essentially causing elimination of blood flow. Furthermore, depending on the amount of electric current, burns may also occur. In his opinion outlawing the electric chair as a method of execution, Justice William M. Connolly of the Nebraska Supreme Court stated that "electrocution inflicts intense pain and agonizing suffering", adding that it is “unnecessarily cruel in its purposeless infliction of physical violence and mutilation of the prisoner’s body.”^[8]

Jumping from height

Jumping from height is the act of jumping from high altitudes, for example, from a window (self-defenestration or auto-defenestration), balcony or roof of a high rise building, cliff, dam or bridge. This method, in most cases, results in severe consequences if the attempt fails, such as paralysis, organ damage, and bone fractures.

In the United States, jumping is among the least common methods of committing suicide (less than 2% of all reported suicides in the United States for 2005).^[4]

In Hong Kong, jumping is the most common method of committing suicide, accounting for 52.1% of all reported suicide cases in 2006 and similar rates for the years prior to that.^[9] The Centre for Suicide Research and Prevention of the University of Hong Kong believes that it may be due to the abundance of easily accessible high rise buildings in Hong Kong.^[10]

There have been several documented cases of suicide by skydiving, by people who deliberately failed to open their parachute (or removed it during freefall) and were found to have left suicide notes.^[11][12] Expert Skydiver and former 22 SAS Soldier Charles (Nish) Bruce QGM committed suicide^[13] following 8 years of mental illness and periods under section by leaping from a Cessna 172 from 5000 feet over Fyfield, Oxfordshire without a parachute whilst on a private flight home from Spain to Hinton Skydiving Centre.^[14] His military history and the manner of his death resulted in extensive media coverage.^{[15][16][17][18][19]} Numerous sources^[20][21] have looked to attribute his breakdown and suicide to Post Traumatic Stress Disorder.^[22]

Firearms

A common suicide method is to use a firearm. Generally, the bullet will be aimed at point-blank range, often at the head or, less commonly, into the mouth, under the chin, or pointed at the chest. Worldwide, firearm prevalence in suicides varies widely, depending on the acceptance and availability of firearms in a culture. The use of firearms in suicides ranges from less than 10% in Australia^[23] to 50.5% in the U.S., where it is the most common method of suicide.^[24]

A failed suicide attempt by firearm may result in severe chronic pain for the patient as well as reduced cognitive abilities and motor function, subdural hematoma, foreign bodies in the head, pneumocephalus and cerebrospinal fluid leaks. For temporal bone directed bullets, temporal lobe abscess, meningitis, aphasia, hemianopsia, and hemiplegia are common late intracranial complications. As many as 50% of people who survive gunshots wounds directed at the temporal bone suffer facial nerve damage, usually due to a severed nerve.^[25]

Research published in the New England Journal of Medicine and the National Academy of Science found an association between household firearm ownership and gun suicide rates,^[26][27] though a study by one researcher did not find a statistically significant association between household firearms and gun suicide rates,^[28] except in the suicides of children aged 5–14.^[28] During the 1980s and early 1990s, there was a strong upward trend in adolescent suicides with a gun,^[29] as well as a sharp overall increase in suicides among those age 75 and over.^[30]

Two separate studies, in Canada and Australia, conducted in conjunction with more restrictive firearms legislation, demonstrated that while legislation showed a decrease in firearms suicide, other methods such as hanging increased. In Australia, the overall rate of suicide continued along an increasing trend, not decreasing until measures specifically aimed to provide support for those intent on suicide were implemented.^[31][32][33]

According to criminologist Gary Kleck, studies that try to link gun ownership to victimology often fail to account for the presence of guns owned by other people.^[34] Research by economists John Lott of the U.S. and John Whitley of Australia indicates that safe-storage laws do not appear to affect juvenile accidental gun deaths or suicides.^[35]

Hanging

When hanging one's self, the subject uses some type of ligature, as in a rope or a cord, to form a noose (or loop) around the throat, with the opposite end secured to some fixture. Depending on the placement of the noose and other factors, the subject strangles or suffers a broken neck. In the event of death, the actual cause often depends on the length of the drop; that is, the distance the subject falls before the rope goes taut.

In a "short drop", the victim may die from strangulation, in which the death may result from a lack of oxygen to the brain. The victim is likely to experience hypoxia, skin tingling, dizziness, vision narrowing, convulsions, shock, and acute respiratory acidosis. One or both carotid arteries and/or the jugular vein may also be compressed sufficiently to cause cerebral ischemia and a hypoxic condition in the brain which will eventually result in or contribute to death. Hanging survivors typically have severe damage to the trachea and larynx, damage to the carotid arteries, damage to the spine, and brain damage due to cerebral anoxia.

In a typical "long drop", the subject is likely to suffer one or more fractures of the cervical vertebrae, generally between the second and fifth, which may cause paralysis or death. In extremely long drops, the hanging may result in complete decapitation.

Hanging is the prevalent means of suicide in pre-industrial societies, and is more common in rural areas than in urban areas.^[36] It is also a common means of suicide in situations where other materials are not readily available, such as in prisons.

Ligature compression

This method involves tightening a ligature around the neck so as to compress the carotid arteries, preventing the supply of oxygen to the brain and resulting in unconsciousness and death. The technique is also associated with certain types of judo holds and restraints, and auto-erotic asphyxiation.^{[37][38][39][40]}

Vehicular impact

Another way of committing suicide is deliberately placing oneself in the path of a large and fast-moving vehicle, resulting in fatal impact.

Rail

Suicide is accomplished by positioning oneself on a railway track when a train approaches or in advance, or driving a car onto the tracks.^[41] Failed attempts may result in profound injuries, such as massive fractures, amputations, concussion and severe mental and physical handicapping.^[42]

Unlike on underground railways, in suicides involving above-ground railway lines, the victim will often simply stand or lie on the tracks, waiting for the arrival of the train. As the trains usually travel at high speeds (usually between 80 and 200 km/h), the driver is usually unable to bring the train to a halt before the collision. This type of suicide may be traumatizing to the driver of the train and may lead to post-traumatic stress disorder.^[43]

Suicides on tracks may take place through the person either jumping onto, walking, lying or sitting on the tracks. Lying on the tracks may result in decapitation. Accidents resulting from people jumping onto the tracks usually occur at daytime. Accidents including people walking, lying or sitting on the tracks usually occur at night when the driver's visibility is reduced, reducing the chance of a failed suicide. People who commit suicide in this manner usually stay at or around the place for the suicide for an extended period of time before the actual suicide.

Europe

In the Netherlands, as many as 10% of all suicides are rail-related.^[44] In Germany, 7% of all suicides occur in this manner.^[45] To deal with an average of three suicide incidents per day, Deutsche Bahn is operating a sanatorium specifically for traumatized train drivers.^[46] In recent years, some German train drivers succeeded in getting compensation payments from parents or spouses.^[47] In Sweden, less densely populated and with a smaller proportion of the population living in proximity of railroad tracks, 5% of all suicides are rail-related. In Belgium, nearly 6 percent of suicides are rail related with a disproportionate amount occurring in the Dutch-speaking region (10% rate in Flanders). There is a low rate of direct death; one in two are failed attempts. The location of many suicides occur at or very close to stations, which is also uncharacteristic of suicides in other European countries. The disruption to the rail system is substantial and families of the victims are financially responsible for the economic loss due to canceled or delayed traffic and costs related to investigation and cleanup.

Japan

Trains on Japanese railroads cause a large number of suicides every year. Suicide by train is seen as something of a social problem, especially in the larger cities such as Tokyo or Nagoya, because it disrupts train schedules and if one occurs during the morning rush-hour, causes numerous commuters to arrive late for work. However, suicide by train persists despite a common policy among life insurance companies to deny payment to the beneficiary in the event of suicide by train (payment is usually made in the event of most other forms of suicide). Suicides involving the high-speed bullet-train, or Shinkansen are extremely rare, as the tracks are usually inaccessible to the public (i.e. elevated and/or protected by tall fences with barbed wire) and legislation mandates additional fines against the suicide victim's family and next-of-kin.^[48]

North America

According to the Federal Railroad Administration, in the U.S., there are 300 to 500 train suicides a year.^[49] A study of completed suicides on railway rights-of-ways by the Federal Railroad Administration found that the decedents tended to live near railroad tracks, were less likely to have access to firearms, and were significantly compromised by both severe mental disorder and substance abuse.^[50]

Reducing the number of rail-related suicides

Methods to reduce the number of rail-related suicides include CCTV surveillance of stretches where suicides frequently occur, often with direct links to the local police or surveillance companies. This enables the police or guards to be on the scene within minutes after the trespassing was noted. Public access to the tracks is also made more difficult by erecting fences. Trees and bushes are cut down around the tracks in order to increase driver visibility.

In southern Sweden, where a suicide hotspot is located south of the university town Lund, CCTV cameras with direct links to the local police have been installed. Similar packages will be installed on other hotspots throughout the nation.

In the Netherlands, where several suicide hotspots are located by rail tracks next to mental wards, loud speakers and strong lights that activate when trespassing is noted, have been installed next to these hotspots.

Metro systems

Jumping in front of an oncoming subway train has a 59% death rate, lower than the 90% death rate for rail-related suicides. This is most likely because trains traveling on open tracks travel relatively quickly, whereas trains arriving at a subway station are decelerating so that they can stop and board passengers.

Different methods have been used in order to decrease the number of suicide attempts in the underground: for instance, deep drainage pits halve the likelihood of fatality. Separation of the passengers from the track by means of platform screen doors is being introduced in some stations, but is expensive.^[51]

Traffic collision

Some suicides are the result of intended car crashes. This especially applies to single-occupant, single-vehicle accidents, "because of the frequency of its use, the generally accepted inherent hazards of driving, and the fact that it offers the individual an opportunity to imperil or end his life without consciously confronting himself with his suicidal intent."^[52] There is always the risk that a car accident will affect other road users; for example, a car that brakes abruptly or swerves to avoid a suicidal pedestrian may collide with something else on the road.

The real percentage of suicides among car accidents is not reliably known; studies by suicide researchers tell that "vehicular fatalities that are suicides vary from 1.6% to 5%".^[53] Some suicides are misclassified as accidents, because suicide must be proven; "It is noteworthy that even when suicide is strongly suspected but a suicide note is not found, the case will be classified an 'accident.'"^[54]

Some researchers believe that suicides disguised as traffic accidents are far more prevalent than previously thought. One large-scale community survey (in Australia) among suicidal persons provided the following numbers: "Of those who reported planning a suicide, 14.8% (19.1% of male planners and 11.8% of female planners) had conceived to have a motor vehicle "accident"... Of all attempters, 8.3% (13.3% of male attempters) had previously attempted via motor vehicle collision."^[55]

Aircraft

Between 1983 and 2003, 36 pilots committed suicide by aircraft in the United States.^[56] There have been well documented suicide attacks by aircraft, including Japanese Kamikaze attacks, and the September 11 attacks. On 24 March 2015, Germanwings co-pilot Andreas Lubitz deliberately crashed Germanwings Flight 9525 into the French Alps to commit suicide, killing 150 people with him.^[57][58]

Poison

Suicide can be committed by using fast-acting poisons, such as hydrogen cyanide, or substances which are known for their high levels of toxicity to humans.^[59] For example, most of the people of Jonestown died when Jim Jones, the leader of a religious sect, organized a mass suicide by drinking a cocktail of diazepam and cyanide in 1978.^[60] Sufficient doses of some plants like the belladonna family, castor beans, Jatropha curcas and others, are also toxic. Poisoning through the means of toxic plants, is usually slower and is relatively painful.^[61]

Pesticide

Worldwide, 30% of suicides are from pesticide poisonings. The use of this method, however, varies markedly in different areas of the world, from 4% in Europe to more than 50% in the Pacific region.^[62] Poisoning by farm chemicals is very common among women in the Chinese countryside, and is regarded as a major social problem in the country.^[63] In Finland, the highly lethal pesticide Parathion was commonly used for suicide in the 1950s. When access to the chemical was restricted, other methods replaced it, leading researchers to conclude that restricting certain suicide methods does little to impact the overall suicide rate.^[64] However, in Sri Lanka, both suicide by pesticide and total suicides declined after first class 1 and later endosulfan were banned.^[65]

Drug overdose

Overdose is a method of suicide which involves taking medication in doses greater than the indicated levels, or in a combination that will interact either to cause harmful effects or increase the potency of one or other of the substances.

An overdose is often the expressed preferred method of dignified dying among members of right-to-die societies. A poll among members of right-to-die society Exit International suggested that 89% would prefer to take a pill, rather than use a plastic exit bag, a CO generator, or use "slow euthanasia".^[66] Death by helium inhalation however is the more common method preferred in practice, largely owing to its reliability.^[67]

Reliability of the drugs method highly depends on chosen drugs and additional measures such as the use of antiemetics to prevent vomiting. Average fatality rate for overdoses in the U.S. is estimated to be only 1.8%.^[68] At the same time, assisted suicide group Dignitas reported no single failure among 840 cases (fatality rate 100%), where an overdose of pentobarbital, the active agent in former hypnotic medication Nembutal, was used in combination with antiemetic drugs.^[69]

While barbiturates (such as Seconal or Nembutal) have long been an option for suicide, they are becoming increasingly difficult for potential suicide victims to acquire. Dutch right-to-die society WOZZ proposed several safe alternatives to barbiturates for use in euthanasia.^[70] The Peaceful Pill Handbook suggests the still easy availability of solutions containing pentobarbital in Mexico, where they are available over-the-counter from veterinarians for animal euthanasia.

A typical drug overdose uses random prescription and over-the-counter substances. In this case, death is highly uncertain, and an attempt may leave a person alive but with severe organ damage, although that itself may in turn eventually prove fatal. Drugs taken orally may also be vomited back out before being absorbed. Considering the very high doses needed, vomiting or losing consciousness before taking enough of the active agent is often a major problem for people attempting this.

Analgesic overdose attempts are among the most common, due to easy availability of over-the-counter substances.^[71] Overdose may also take place when mixing medications in a cocktail with one another, or with alcohol or illegal drugs. This method may leave confusion over whether the death was a suicide or accidental, especially when alcohol or other judgment-impairing substances are also involved and no suicide note was left behind.

Carbon monoxide

A particular type of poisoning involves inhalation of high levels of carbon monoxide. Death usually occurs through hypoxia. In most cases carbon monoxide (CO) is used because it is easily available as a product of incomplete combustion; for example, it is released by cars and some types of heaters. A failed attempt can result in memory loss and other symptoms.^[72][73][74]

Carbon monoxide is a colorless and odorless gas, so its presence cannot be detected by sight or smell. It acts by binding preferentially to the hemoglobin in the victim's blood, displacing oxygen molecules and progressively deoxygenating the blood, eventually resulting in the failure of cellular respiration, and death. Carbon monoxide is extremely dangerous to bystanders and people who may discover the body, so "Right to Die" advocates like Philip Nitschke recommend the use of safer alternatives like nitrogen, for example in his EXIT euthanasia device.

In the past, before air-quality regulations and catalytic converters, suicide by carbon monoxide poisoning would often be achieved by running a car's engine in a closed space such as a garage, or by redirecting a running car's exhaust back inside the cabin with a hose. Motor car exhaust may have contained up to 25% carbon monoxide. However, catalytic converters found on all modern automobiles eliminate over 99% of carbon monoxide produced.^[75] As a further complication, the amount of unburned gasoline in emissions can make exhaust unbearable to breathe well before losing consciousness.

The incidence of suicide by carbon monoxide poisoning through burning charcoal, such as a barbecue in a sealed room, appears to have risen. This has been referred to by some as "death by hibachi".^[76] As with other suicide methods, charcoal burning suicide attempters can live from the attempt, which typically leaves a person with severe brain damage due to cerebral anoxia.

Other toxins

Detergent-related suicide involves mixing household chemicals to produce hydrogen sulfide or other poisonous gases.^{[77][78][79][80]} The suicide rates by domestic gas fell from 1960 to 1980.^[81]

Several creatures, such as spiders, snakes, and scorpions, carry venoms that can easily and quickly kill a person. These substances can be used to conduct suicide. For example, Cleopatra supposedly had an asp bite her when she heard of Marc Antony's death.^[82]

Disease

There have been several documented cases of deliberately contracting a fatal disease such as HIV/AIDS as a means of suicide.^[83][84][85]

Immolation

Immolation usually refers to suicide by fire. It has been used as a protest tactic, most famously by Thích Quảng Đức in 1963 to protest the South Vietnamese government's systematic anti-Buddhist, pro-Catholic policies; by Malachi Ritscher in 2006 to protest the United States' involvement in the Iraq War; and by Mohamed Bouazizi in Tunisia which started the Tunisian Revolution in 2011 and the Arab Spring.

Self-immolation was also carried out as a ritual known as sati in certain parts of India, where a Hindu wife immolated herself in her dead husband's funeral pyre, either voluntarily or by coercion.^[86]

The Latin root of "immolate" means "sacrifice", and is not restricted to the use of fire, though in common US media usage the term immolation refers to suicide by fire.

This method of suicide is relatively rare due to the long and painful experience one has to go through before death sets in. This is also contributed to by the ever-present risk that the fire is extinguished before death sets in, and in that way causes one to live with severe burnings, scar tissue, and the emotional impact of such horrific injuries.

Volcano

Suicide by volcano involves jumping into molten lava in an active volcanic crater, fissure vent, lava flow or lava lake. The actual cause of death may be as a result of the fall (see jumping from height), contact burns, radiant heat or asphyxiation from volcanic gases. According to some ancient sources, philosopher Empedocles jumped into the Aetna trying to make everybody believe that he had disappeared from the Earth to become a god; this was frustrated when the volcano spat out one of his bronze sandals. Modern suicides have taken place in numerous volcanoes but the most famous is Mount Mihara in Japan. In 1933, Kiyoko Matsumoto committed suicide by jumping into the Mihara crater. A trend of copycat suicides followed, as 944 people jumped into the same crater over the following year.^[87] Over 1200 people attempted suicide in two years before a barrier was erected.^[88] The original barrier was replaced with a higher fence topped with barbed wire after another 619 people jumped in 1936.^[89][90]

Ritual suicide

Ritual suicide is performed in a prescribed way, often as part of a religious or cultural practice.

Seppuku

Seppuku ("cut-belly", used in writing) or hara-kiri ("belly slitting", used when talking) is a Japanese ritual method of suicide, practiced mostly in the medieval era, though some isolated cases appear in modern times. For example, Yukio Mishima committed seppuku in 1970 after a failed coup d'état intended to restore full power to the Japanese emperor.^[91] Unlike other methods of suicide, this was regarded as a way of preserving one's honor. The ritual is part of bushido, the code of the samurai.

As originally performed solely by an individual, it was an extremely painful method by which to die. Dressed ceremonially, with his sword placed in front of him and sometimes seated on special cloth, the warrior would prepare for death by writing a death poem. The samurai would open his kimono, take up his wakizashi (short sword), fan, or a tantō and plunge it into his abdomen, making first a left-to-right cut and then a second slightly upward stroke. As the custom evolved, a selected attendant (kaishakunin, his second) stood by, and on the second stroke would perform daki-kubi, where the warrior is all but decapitated leaving only a slight band of flesh attaching the head to the body, so as to not let the head fall off and roll on the ground, which was considered dishonorable in feudal Japan. The act eventually became so highly ritualistic that the samurai would only have to reach for his sword, and his kaishakunin would execute the killing stroke. Later still, there would be no sword, but something like a fan for which the samurai would reach.

Autosacrifice

Human sacrifice was a religious activity throughout Mesoamerica. In Aztec and Maya culture, autosacrifice involving self-decapitation by priests and kings is depicted in artworks.^[92][93] The sacrifice is usually depicted holding an obsidian knife or axe to the side of the neck.^[93][94]

Some forms of Durga worship in Indian Hinduism involve a male devotee offering himself as a sacrifice through ritual self-decapitation with a curved sword. This is designed to obtain a favor from the deity for a third party.^[95][96]

Starvation

A hunger strike may ultimately lead to death. Starvation has been used by Hindu and Jain monks as a ritual method of penance (known as Prayopavesa and Santhara respectively) or as a method of speeding up one's own death,^[97] and Albigensians or Cathars also fasted after receiving the 'consolamentum' sacrament, in order to die while in a morally perfect state.^[98] This method of death is often associated with political protest, such as the 1981 Irish Hunger Strike by Irish republican paramilitary prisoners demanding prisoner of war status, of whom ten died. The explorer Thor Heyerdahl refused to eat or take medication for the last month of his life, after he was diagnosed with cancer.^[99]

Anorexia nervosa has been referred to as a subconscious form of suicide.^[100] However, an anorexia nervosa death caused by self-starvation is not listed on death certificates as suicide. In the UK, refusal to adhere to norms regarding food and drink consumption can lead to being detained, treated and even force fed under section 3 of the Mental Health Act 1983. The effects of this can be substantial and may result in 'sectioning/ Involuntary commitment, with some cases demonstrating a level of persistence from mental health professionals in the resistance of such methods.^[101] The effects of force feeding have even been likened to "sexual assault" by sociologist aficionados like June Purvis (Professor of Sociology at Portsmouth University); who cites the ill treatment of women in the Suffragette movement. One argument, put forward by the historian and journalist George Dangerfield denoted the treatment as "No more than extremely unpleasant". The women themselves claiming the process was "frightfully indignified".^[102] The moral issues faced by medical professionals handling such treatments are still present today. American news networks recorded a case of a navy male nurse who faced a Court Martial at Guantanamo Bay for refusing to force-feed detainees on ethical grounds.^[103] This revelation caused conflict amongst many in the US when a video was leaked of a distressed Gitmo detainee coughing up blood during the procedure. ^[104]

Dehydration

Death from dehydration can take from several days to a few weeks. This means that unlike many other suicide methods, it cannot be accomplished impulsively. Those who die by terminal dehydration typically lapse into unconsciousness before death, and may also experience delirium and deranged serum sodium.^[105] Discontinuation of hydration does not produce true thirst, although a sensation of dryness of the mouth often is reported as "thirst." The evidence this is not true thirst is extensive and shows the ill feeling is not relieved by giving fluids intravenously, but is relieved by wetting the tongue and lips and proper care of the mouth. Patients with edema tend to take longer to die of dehydration because of the excess fluid in their bodies.^[106]

Terminal dehydration has been described as having substantial advantages over physician-assisted suicide with respect to self-determination, access, professional integrity, and social implications. Specifically, a patient has a right to refuse treatment and it would be a personal assault for someone to force water on a patient, but such is not the case if a doctor merely refuses to provide lethal medication.^[107] But it also has distinctive drawbacks as a humane means of voluntary death.^[108] One survey of hospice nurses found that nearly twice as many had cared for patients who chose voluntary refusal of food and fluids to hasten death as had cared for patients who chose physician-assisted suicide.^[109] They also rated fasting and dehydration as causing less suffering and pain and being more peaceful than physician-assisted suicide.^[110] Other sources, however, have noted very painful side effects of dehydration, including seizures, skin cracking and bleeding, blindness, nausea, vomiting, cramping and severe headaches.^[111] There can be a fine line between terminal sedation that results in death by dehydration and euthanasia.^[112]

Suicide attack

A suicide attack is an attack in which the attacker (attacker being either an individual or a group) intends to kill others and intends to die in the process of doing so (e.g. Columbine, Virginia Tech and 9/11). In a suicide attack in the strictest sense, the attacker dies by the attack itself, for example in an explosion or crash caused by the attacker. The term is sometimes loosely applied to an incident in which the intention of the attacker is not clear, though he is almost sure to die by the defense or retaliation of the attacked party, e.g., "suicide by cop", that is, menacing or assaulting an armed police officer with a weapon or apparent or proclaimed harmful intent which all but ensures that the officer will use deadly force to terminate the attack. This can also be referred to as murder/suicide.

Such attacks are typically motivated by religious or political ideologies, and have been carried out using numerous methods. For example, attackers might attach explosives directly to their bodies before detonating themselves close to their target, also known as suicide bombing. They may use a car bomb or other machinery to cause maximum damage (e.g. Japanese kamikaze pilots during World War II).

Indirect suicide

Indirect suicide is the act of setting out on an obviously fatal course without directly committing the act upon oneself. Indirect suicide is differentiated from legally defined suicide by the fact that the actor does not pull the figurative (or literal) trigger. Examples of indirect suicide include a soldier enlisting in the army with the express intention and expectation of being killed in combat, or someone could be provoking an armed officer into using lethal force against them. The latter generally called "suicide by cop". In some instances the subject commits a capital crime in hope of being sentenced to death.

Evidence exists for numerous examples of suicide by capital crime in colonial Australia. Convicts seeking to escape their brutal treatment would murder another individual. This was necessary due to a religious taboo against direct suicide. A person committing suicide was believed to be destined for hell, whereas a person committing murder could absolve their sins before execution. In its most extreme form, groups of prisoners on the extremely brutal penal colony of Norfolk Island would form suicide lotteries. Prisoners would draw straws with one prisoner murdering another. The remaining participants would witness the crime, and would be sent away to Sydney as capital trials could not be held on Norfolk Island, thus earning a break from the Island. There is uncertainty as to the extent of suicide lotteries. While surviving contemporary accounts claim that the practice was common, such claims are probably exaggerated.^[113]

Animal attacks

Some people have chosen to indirectly commit suicide by being attacked by predatory animals such as sharks and crocodiles, and in some cases the person has been eaten alive; for example, in 2011 in eastern South Africa a depressed man (who wanted to be attacked by a crocodile) jumped into a river and was consumed by a crocodile.^[114] Similarly, in 2002 a depressed woman killed herself by jumping into a crocodile pond at the Samutprakarn Crocodile Farm and Zoo in Thailand.^[115] In 2014 a second woman killed herself by jumping into the same crocodile pond in Thailand.^[116] Both women were eaten alive.

In media

A number of books have been written as aids in suicide, including Final Exit and The Peaceful Pill Handbook, the latter of which overlaps with euthanasia methods. Many books on this topic have been challenged and banned due to controversy. However, ones such as The Complete Manual of Suicide state that they neither encourage nor discourage suicide.

There are also suicide sites. These sites include suicide bridges such as the Golden Gate Bridge (which has had 1558 accounted deaths as of 2012, with only 33 having survived)^[117] and Lover's Leaps, which are named so for their association with legends of romantic tragedy.

See also

• Advocacy of suicide
• Suicide legislation
• Suicide prevention
• List of suicides from antiquity to the present
• List of suicides in the 21st century

Further reading

• Docker, Chris (2015). Five Last Acts II (2nd ed.). USA: Createspace. p. 446. ISBN 978-1511988506. 
• Docker, Chris (2015). Five Last Acts – The Exit Path. USA: Createspace. p. 822. ISBN 978-1512176445. 
• Humphry, Derek (1997). Final Exit: The Practicalities of Self-Deliverance and Assisted Suicide for the Dying. Dell. p. 240. 
• Nitschke, Philip (2007). The Peaceful Pill Handbook. US: Exit International. p. 211. ISBN 0-9788788-2-5. 
• Stone, G. (2001). Suicide and Attempted Suicide: Methods and Consequences. New York: Carroll & Graf. ISBN 0-7867-0940-5. 

References

External links

• Hawton, K; Clements, A; Simkin, S; Malmberg, A (1 June 2000). "Doctors who kill themselves: a study of the methods used for suicide". QJM. Oxford University Press. 93 (6): 351–357. doi:10.1093/qjmed/93.6.351.