Reasoning for autonomous suicide? A qualitative approach to pre-suicidal decision-making

The article presents empirical data concerning the meaning of freedom and autonomy in the emotional-cognitive processes that govern pre-suicidal decision-making. The data is derived from a qualitative interview study conducted between December 2012 and July 2014 on an intensive care unit in Germany. Twelve patients (three male, nine female; seven with pre-diagnosed mental illness) who had attempted suicide by intoxication were included. The narrative biographical approach chosen allows to capture the individuals' experiences preceding their decisions for suicide and provides insights into the biographical contexts of their decisions. Most strikingly, the narratives underline the essential importance of interpersonal relationships as well as an ambivalent reciprocity of cognitive and emotional processes in pre-suicidal reasoning, while ideas of autonomy and decision-making capacity traditionally address rational deliberation. This divergence between patients' subjective perceptions and scholarly conceptualisations of autonomous suicide is in line with increasing criticism of conventional approaches, given that they ignore essential elements of human existence, such as values, emotions, and social interdependence. The empirical findings suggest moving beyond the idea of autonomous decision-making for suicide as a rational procedure and instead conceptualise the pre-suicidal decision-making process as a highly emotional phenomenon within a relational context. Acknowledging that suicidality is not only linked to cognitive considerations but also intertwined with or predominantly controlled by emotional dimensions, such as despair, crisis, and marginalisation, we argue that further evaluation tools are required to address suicidality in all its facets. In moving beyond the mere consideration of cognitive functions, this approach is particularly suitable for representing the reality of persons with mental illness. This provides urgently needed guidance for clinical practice, considering that the latest German jurisdiction on physician-assisted suicide holds that the right to a self-determined death cannot be refused unless an acute psychiatric condition directly caused the suicide wish.