Intervention

Reaching out

Print edition : September 16, 2016
Decriminalising suicide is a step in the right direction. Early identification and effective management are the key to ensuring that those who attempt suicide receive the care they need.

A girl and a boy loved each other. The families objected. Unable to bear the stress of the situation and unable to go against her family, the girl consumed poison. Seems like a scene from a movie? Far from it. It is a real life story, and a sad story at that. The girl was admitted to hospital and saved. The police booked a case of attempted suicide and sent the girl home. Nobody in the girl’s neighbourhood knew of this incident. But that was not to be for long. The next morning policemen came calling, asking for the girl who had attempted suicide because of love failure. And the entire neighbourhood got to know about the incident. The police left after their routine call, but the girl could not take it anymore—the shame and the public humiliation got to her. She hanged herself that night. And this time she succeeded… to die.

This is what Section 309 of the Indian Penal Code (IPC) does to people who attempt suicide and happen to survive. A legacy of the colonial regime, the archaic Section 309 makes attempting suicide a criminal offence, subjecting the survivor to further stress and emotional pain. But things are set to change now thanks to the passage of the Mental Health Care Bill, 2016, in the Rajya Sabha, which bypasses Section 309. The Bill states that:

115. (1) Notwithstanding anything contained in section 309 of the Indian Penal code, any person who attempts to commit suicide shall be presumed, unless proved otherwise, to have severe stress and shall not be tried and punished under the said Code.

(2) The appropriate government shall have a duty to provide care, treatment and rehabilitation to a person having severe stress and who attempted to commit suicide to reduce the risk of recurrence of attempt to commit suicide.

Decriminalising suicide is a step in the right direction and has been widely welcomed by all, including traditional adversaries.

To truly understand the significance of decriminalising suicide, it is imperative that we understand the act of suicide itself. Suicide is the tragic and untimely loss of human life, all the more devastating and perplexing because it is a conscious volitional act. Suicides have occurred since the beginning of recorded history. A decision to commit suicide is influenced by several interacting factors—personal, social, psychological, cultural, biological and environmental. In recent decades, knowledge about suicidal behaviour has increased greatly. Research has helped identify the many risk and protective factors for suicide, both in the general population and in vulnerable groups. Cultural variability in suicide risk has also become apparent, with culture having roles both in increasing risk and in protecting people from suicidal behaviour. Despite all this knowledge, the absence of supporting laws and a national strategy makes it impossible to reach out to those with suicidal thoughts.

Chilling statistics

Every year, more than 800,000 people commit suicide worldwide, making it a major public health problem. Amongst the youth—people in the age group of 15-29—suicide is now the second leading cause of death. An estimated 75 per cent of suicides occur in low- and middle-income countries. In India, according to the National Crime Records Bureau, 1,31,666 people died by suicide in 2014; the World Health Organisation (WHO) estimated 2,58,075 suicides in 2012. The national suicide rate is 10.6 (the number of persons dying by suicide per 100,000 of population). The persistent pattern in the past two decades shows that the southern States of India have higher suicide rates than the northern States. The enormity of the situation dawns on us when we consider the fact that for every death by suicide, 20 people attempt suicide. This suggests that even by a conservative estimate, there are at least three million suicide attempts or rather crimes according to Section 309.

Much to the credit of our judiciary, past records show that while people have been booked under Section 309 for attempting suicide, not one case has resulted in conviction. All that the Section has done is to add to the burden and stigma of the distressed person and his/her family as they face interrogation and spend their time and energy to appear before the courts of law.

As far back as June 1971, the Law Commission, in its 42nd report, recommended the repeal of Section 309 saying that the penal provision was harsh and unjustified. The Indian Penal Code (Amendment) Bill, which provided for the omission of Section 309, was passed by the Rajya Sabha in 1978. However, the Bill lapsed as the Lok Sabha was dissolved before it could be passed. A variety of legal arguments and cases followed, and unfortunately a five-member Constitution Bench recommended retention of the provision. The following were some of the objections/myths surrounding decriminalisation of suicide:

1. Decriminalisation will result in an increase in suicide attempts. In other words, Section 309 acts as a deterrent to those contemplating taking their life.

On the contrary, it has been proven that suicide rates tend to decrease after decriminalisation. Sri Lanka, for example, decriminalised attempted suicide and has witnessed a reduction in suicides after that as effective and immediate intervention became more feasible. It is highly unlikely that a person under mental and emotional distress, who is contemplating to end his/her own life, is going to be in a frame of mind to consider whether it is lawful or not. Hence, this law has no deterrent effect. Decriminalising suicides, on the other hand, will ensure timely emergency treatment for those who attempt suicide as there will be no medico-legal issues. It will also prevent under-reporting of attempted suicides and enable one to gauge the true extent of the problem and devise effective strategies for the prevention of suicides.

2. Decriminalisation interferes with the “right to live” and the “right to die” (euthanasia).

The debate on the right to live and the right to die is a different one. What decriminalising attempt to suicide hopes to ensure is to recognise the emotional distress and psychological pain of a person who is unable to face his/her life, of someone who is already vulnerable and desperate. To be then treated as a criminal and to be subjected to the ignominy of police interrogation will cause increased distress, shame and guilt and lead to further suicide attempts. Research has shown that a person who has attempted suicide once is vulnerable to further attempts for a period of about 18 months. He/she needs support through this period and this cannot be done by putting him/her behind bars.

3. Decriminalisation will thwart the police in taking action against those abetting suicide.

All countries that have decriminalised attempt to suicide have retained the abetment to suicide law. Hence, the efficacy of Section 306 remains undiluted.

Why repeal Section 309?

Persistence with Section 309 presents the following difficulties:

1. Emergency treatment for those who attempt suicide is not readily accessible as they are referred by local hospitals and doctors to tertiary centres in view of the medico-legal aspects. By then the golden hour gets over, resulting in loss of lives.

2. Those who attempt suicide are already distressed and in psychological pain and for them police interrogation will only lead to increased distress, shame and guilt. This may sometimes result in further suicide attempts.

3. For a family in turmoil, dealing with police procedures adds to its woes.

4. It leads to a gross under-reporting of attempted suicides, thereby leading to the magnitude of the problem remaining unknown. Unless one is aware of the nature and extent of the problem, effective intervention is not possible.

5. As many suicide bids are categorised as accidental poisoning and the like, emotional and mental health support is not available to those who attempt suicide.

In the light of all these difficulties and appeals by organisations such as SNEHA, the Indian Psychiatric Society, the WHO and the International Association for Suicide Prevention (IASP) to the judiciary and policymakers, the Law Commission in its Report no. 210 (2008) strongly recommended the repeal of Section 309.

The WHO, too, in its first World Suicide Report released on September 5, 2014, stated that of the 192 countries, only 25 had specific laws and punishment for attempted suicide. It recommended decriminalisation of attempted suicide. Besides, India is also a signatory to the WHO Mental Health Action Plan 2013-2020 and is committed to reducing the suicide rate by 10 per cent by 2020.

Prevention

An important clause in the Mental Health Care Bill, Section 29 (2), is

Without prejudice to the generality of the provisions contained in subsection (1), the appropriate government shall, in particular, plan, design and implement public health programmes to reduce suicides and attempted suicides in the country.

Despite evidence that many deaths are preventable, suicide has too often been a low priority for governments and policymakers. This clause will help fructify a comprehensive, multisectoral, nationwide suicide prevention strategy. A national strategy indicates a government’s commitment to dealing with the issue of suicide. Typical national strategies comprise a range of prevention strategies such as surveillance, means restriction, media guidelines, stigma reduction, and raising of public awareness as well as training for health workers, educators, the police and other gatekeepers. They also usually include crisis intervention services and postvention.

A national strategy for suicide prevention would necessarily require coordination and collaboration among various sectors of society, both public and private, and health and non-health sectors such as education, labour, agriculture, business, justice, law, defence, social, politics and the media. These efforts must be comprehensive, integrated and synergistic as no single approach can impact an issue as complex as suicide. Health-care services need to incorporate suicide prevention as a core component.

Mental disorders and harmful use of alcohol contribute to many suicides in India. Early identification and effective management are the key to ensuring that people receive the care they need.

Community support

Communities play a critical role in suicide prevention. They can provide social support to vulnerable individuals and engage in follow-up care, fight stigma and support those bereaved by suicide. Furtherance of protective factors will help build for the future—a future in which community organisations provide support and appropriate referrals to those in need of assistance, families and social circles enhance resilience and intervene effectively to help loved ones, and there is a social climate where help-seeking is no longer taboo and public dialogue is encouraged.

There are a number of measures that can be taken at the community, health services and national levels to reduce suicides. They include

  • Reducing access to the means of suicide (for example, pesticides and medication);
  • Reducing availability and consumption of alcohol;
  • Effective treatment of people with mental disorders (particularly those with depression, alcoholism and schizophrenia);
  • Following up people who have made suicide attempts;
  • Responsible media reporting;
  • Training primary health care workers; and
  • Crisis intervention services and postvention.

Given the paucity of trained mental health professionals in our country (0.3 psychiatrist for 1,00,000 people) and the stigma associated with mental health disorders, it is imperative that more of us become aware of suicidal behaviour.

It is time we acknowledged and accepted the increasing emotional stress that our daily lives heap on us; it is time we recognised suicides for what they truly are—a cry for help. It is not a crime, not a cowardly act, not an act to gain attention by using life as bait. It is an act of desperation, of hopelessness and utter helplessness. It is time we showed our fellow human beings a little care and helped them seek timely support for their distress lest we should fail them as a friend, a colleague and a relative.

Every year, September 10 is observed as the World Suicide Prevention Day. The theme for this year (as conceived by the IASP and the WHO) is “Connect. Communicate. Care”. It clearly defines the role that each of us can play in the life of someone who is feeling depressed, distressed, desperate and suicidal. Let us listen to this cry for help and resolve to do our best for another human being in our midst.

Dr Lakshmi Vijayakumar is a consultant psychiatrist and the founder of SNEHA, a voluntary organisation working for the last 30 years towards prevention of suicide in India. She is a member of the World Health Organisation’s International Network of Suicide Prevention and Research. She is the recipient of the Ringel Service Award (2015) of the IASP and has also been conferred the Honorary Fellow of Royal College of Psychiatrists (FRCPsych–Hon.), U.K. for her work in suicide prevention.

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