DESERVING AND UNDESERVING SUICIDES

Dr Theodore Dalrymple suggests a

way in which the NHS can save lives and £50 million a year

WHAT IS the commonest single cause of emergency medical (as compared to surgi- cal) admission to hospital among people under 50 years of age? Is is heart attack, stroke, or pneumonia perhaps? Meningitis, nephritis or haemophilia? No, it is self-poi- soning, known also as overdosing, attempt- ed suicide, self-harm and parasuicide. There are about 100,000 cases each year.

This behaviour is so commonly encoun- tered that hospital staff are inclined to believe that it was always as prevalent as it is now. This is not so. It grew to epidemic proportions only in the late 1950s, and reached a peak in the Seventies. The fre- quency declined somewhat during Mrs Thatcher's tenure of office (I expect to see any day now a paper in the British Medical Journal conclusively demonstrating on the basis of these figures that Thatcherism makes you happy), but there are signs that it is rising again.

There are still undeveloped countries in the world where such behaviour is unknown, or at least very infrequent. Indeed, one can almost measure the advance of westernisation, if not of eco- nomic progress itself, by the frequency with which a country's young women resort to the pill bottle. The nature of the pills taken can tell you something about the state of the public health, too: in the Philippines, for example, the most fre- quently ingested pill for the purpose of overdosing is isoniazid, an antituberculous drug.

I should have liked to assert categorical- ly that the rise of overdosing in this coun- try was the result of the decriminalisation of suicide which occurred at about the same time but, unfortunately for this theo- ry, Britain was not alone in experiencing the epidemic of self-destructive gestures. It happened simultaneously all over western Europe (especially in the northern coun- tries), and in the United States also, at a time of unprecedented prosperity. Howev- er, it would be as misleading to suggest that prosperity caused overdosing as to suggest that overdosing caused prosperity.

In so far as I have a theory at all about this unfortunate proclivity, it is that the Fifties, Sixties and Seventies were a time of emotional incontinence. Where once one kept one's distress decently to oneself, and prided oneself on overcoming hard- ships without help, or confided distress only to a close friend, it became permissi- ble, even fashionable, to wear one's dis- content on one's sleeve. Fortitude was frowned upon, while contentment was seen as a sign of diseased sensibility. How could anyone be happy while there was so much suffering in Central Africa? The less articulate took to the pills as yuppies to the cellular telephone.

So much for grand theory. But why do individuals, and so many of them, take overdoses? It is not to be supposed that nearly 100,000 people act for precisely the same reasons (the number of people tak- ing overdoses does not equal the number of cases of overdose because some people take more than one). Epidemiology never- theless gives us a few clues.

Overdosing is an activity of adolescents and young adults. More females than males do it, though the males have been trying hard of late to catch up. The unem- ployed, the sick, the lower classes, the unskilled, the uneducated are overrepre- sented in the ranks of the overdosers. A third have taken a drink when they swal- low the pills, and many have just had a row with parents or a lover who has threatened to leave them.

Very commonly, the overdose is an attempt at blackmail. Either you return to me, stop seeing the other woman, put up with my outrageous behaviour, let me stay 'My A level results were academic . .

out all night, stop drinking, let me play my music full blast at 3 o'clock in the morning, or I'll kill myself, and then you'll be sorry. Often it works, if not the first time, then the second or the third, because those at whom the behaviour is directed find it frightening. But relationships which have to be cemented with suicide threats are rarely destined for happiness. Interestingly, this form of blackmail is one in which the finan- cial cost falls not on the blackmailed but upon a third party, namely the taxpayer: of which more later.

Sometimes — perhaps in one in ten cases — the overdose is the result of a truly tragic situation. By tragedy, I exclude those predicaments which are largely the result of the fecklessness, foolishness or callow- ness of the overdoser. I refer mainly to the cases of young Indian girls who, having been brought up in this country, find it impossible either to obey or disobey the dictates of a tradition which is no longer fully their own; to cases of domestic vio- lence, in which women, after years of intimidation and terror, finally decide they can bear no more, and in their isolation do not know where to turn; and to cases among the old, who often have lamentably many reasons for wishing themselves dead.

The great mass of overdoses, however, remain an attempt to bring someone to heel or to 'manipulate the environment', as the textbooks have it. If the environment were different, those who take them might think more carefully about burdening the public financially with their woes. The aver- age cost of treating an overdose is (at a conservative guess) £500, and so the total cost to the public per year of this irritating and often unethical behaviour is £50 mil- lion.

I wish to make a proposal, therefore, which is even more modest that Dean Swift's for preventing the children of Ire- land from becoming a burden upon their parents or country.

To charge patients the costs of their treatment (plus the costs of recovering those costs) would be what social workers — admittedly in a rather different context — call 'empowering': in other words, it would enable people to gain control of their own lives. Behaviour which previously seemed an instantaneous response to dis- tress and therefore virtually automatic would miraculously prove to have been under conscious control all along. There is, after all, nothing quite like expense for concentrating people's minds.

I can quite see that there might be objec- tions to my proposal. But surely criteria could be laid dawn to distinguish between the deserving and undeserving cases. Is not the failure to make such distinctions at the heart of our malaise? And my proposal might even save lives as well as money, for I have seen quite a few young men die of an overdose when all they wanted was the agreement of their girlfriend to come to a party with them.