Social stigma in suicidal behavior : bioethical reflections

An integrative review on the theme of the social stigma imposed on individuals who have attempted suicide was conducted bringing to the fore reflections from a perspective of bioethics. The research was conducted in electronic databases. Only scientific articles by peer reviewed scientific journals with available abstracts were included. There were no limits to the year and language of publication. Two hundred and twenty-seven manuscripts were found in the first phase of the search. Only 22 complete texts were included in the study after the complete texts had been read. Despite the limitations of the research, it is believed that deeply studying the stigma of suicide can contribute significantly to patients who have attempted suicide. It is concluded that the study of this topic represents a range of bioethical discussions, forming, as it does, part of a phenomenon that affects aspects related to the autonomy and protection of the person.

Social stigma in suicidal behavior: bioethical reflections http://dx.doi.org/10.1590/1983-80422015232080 For the World Health Organization (Organização Mundial da Saúde -OMS) 1 , suicide can be judged as an act that is deliberate and carried out by someone with complete awareness of its final result.In turn, when suicide is not successful, it becomes classified by the literature as attempted suicide.Moreover, it can be considered that, as much the attempt of suicide as the act of suicide itself are motivated by ideations, that is, thoughts generally related to worthlessness, which bring the individual to cogitate and plan his own death 2 .
Still, despite the relative efforts of prevention, the suicidal act still is presented as something unexpected, which should be analyzed in a broad way, since its occurrence many times is given by the summation of risk factors, as well as the inability of the individual to resolve conflicts 3 .These issues, aggregated to the increase of prevalence rates of suicide and attempted suicide in Brazil, engender constant and necessary discussions about the referral of new preventive measures 4 .
Another aspect relevant to the study of suicidal behavior concerns the complexity of the event even after its occurrence, in which it is understood that the act affects not only the individual who made the attempt, but also all those who, in a certain way, live with him 5 .Furthermore, according to what Sand and colleagues 6 claim, historically, people who commit suicide are seen in a more negative way, if compared with individuals that die from other causes.Thus, it can be said that, in a certain way, suicidal behavior imputation of stigmas, those which can contribute negatively to the development of therapeutic intervention 7 .
Faced with these issues and the attempt to better understand the repercussions of the social stigma of suicide, the present study is aimed at correlating it to the theme of bioethical reflection, considered important to deepen the comprehension of this phenomenon.

Method
The paper is based on the conducting of an integrative type of literature review, which consists of the localization and consultation of diverse sources of information, guided by the explicit objective of the collection of more generic or more specific materials related to a certain topic 7 .For the surveying of the articles, it was opted to conduct a search in the electronic databases Periodicals Portal of Capes/ MEC and Pubmed (Portal de Periódicos da Capes/ MEC e Pubmed).The following descriptors in health science were utilized: "attempted suicide", "social stigma" and "bioethics", as much in isolated as in combined form, in this case conjugated as Boolean operators "and" and "or".The search strategy consisted of a systematic method, with restriction of data only by type of document, including articles of periodicals reviewed in pairs.Texts whose abstracts would be available for reading, without restriction of language, were included.In the search, there was no limit of year and type of publication.The period of the search took place in the month of February of 2014.In accordance with the criteria, 35 articles were identified in the Periodicals Portal of Capes/MEC and Pubmed.Initially the reading of titles and abstracts was conducted, selecting those which were most pertinent to the theme.
In a second time phase, it was opted to conduct the reading of full texts, which totaled 22 articles in the Pubmed database.For the evaluation of the manuscripts, the technique of thematic content analysis was utilized, which corresponds to the dismemberment of the text analyzed in units by analogical regroupings 9 , in a way that the interpretation of the material was divided into four topics: a) critical appraisal of the material; b) decomposition of essential elements; c) grouping and classification; d) final analysis.
With the aim of providing theoretical-scientific input for the issues and objectives of the study, searches were conducted within the reference lists of the selected articles were conducted, in addition to the description of their results.The studies were read individually by two researchers.When there were disagreements between them, a third researcher was consulted to offer an opinion about whether or not to include the article.At the end of the analyses, six articles were included in the review.
It was decided to present the data throughout the study in a descriptive table, containing the authors' most relevant information about the stress factors.

Results and discussion
In Table 1, the characteristics of the studies included are presented according to periodical, impact factor, and year of publication.The findings reveal that, the greatest number of articles was published in the years 2010 to 2013.The results indicate that the major area of concentration of the publications Social stigma in suicidal behavior: bioethical reflections http://dx.doi.org/10.1590/1983-80422015232080 was Medicine, in which the majority of studies -86% -were published in psychiatry periodicals.
Galileu and colleagues 10 highlight the participation of Brazil in the increase of the world production of scientific data in the field of psychiatry.According to the authors, in 2004, Brazil was already responsible for 0.4% of the articles published in periodicals related to research in the field of psychiatry/psychology, with 3.01 citations per article, obtaining one of the best indices to which are compared with the innumerous scientific fields, only 12% below the world index of 3.43 citations per article 11 .Despite the significant national findings, in the study few articles originating from Brazilian research or publications in periodicals of the country were included.
The impact factors of the publications were analyzed with respect to classification in terms of the level of evidence.Of the six articles included in the study, five obtained an impact above 1 point.This criterion corresponds to a bibliometric measure which enables a reflection on the quality of the periodical in terms of citation and access, thus providing some of the best evidence relative to the particular theme 12 .
In Table 1, the studies are also presented according to their authors, year of publication, research design and the authors' conceptions about the stigma after attempted suicide.Subsequently, the relevant points for discussion are highlighted, such as understanding of suicidal behavior, history and repercussions of the stigma of suicidal behavior and bioethical reflections on the stigma surrounding suicidal behavior.
It is clear that all the authors emphasize that the stigma is something harmful to the person who attempted suicide and that these labels tend to somehow hinder care with these individuals.Conforming also, Buus and colleagues 5 , highlight that the stigma affects not only the subject, but all the relatives, and that the marks of such association may be directly associated with new attempts.In addition, Reynders and colleagues 13 claim that these labels can also culminate in other co-morbidities, such as the predisposition to the use of psychotropic substances, or hinder the help-seeking process, because they feel discriminated against and marginalized.At the same time, Dyregrov 14 shows the positive tendencies, since his study allows us to observe that in the societies where the stigma is not associated or disconnected, the search for help is likely to increase considerably.
Sudak and colleagues 15 note that there are still matters of concern such as the fact that the stigma of mental illness is more accepted than attempted suicide.They warn that in both cases the stigma must be disconnected, as it may further compromise the clinical condition of both the carrier of the mental disorder and the individual who made the attempt 16 .
Table 1 Synthesis of the most significant results of the articles included according to title of the article, authors, year of publication, periodical, impact factor and research design and the authors' comments on the subject, obeying the inverse chronological order of publication, from 2014 to 2005.

Research design
Conceptions of the authors about the stigma after the suicide attempt The internal shame of the stigma was positively associated with a higher intention of using psychotropic drugs, after the suicide attempt, while the stigma was negatively associated with the intention to seek help from a psychotherapist According to the author, the act of suicide can be considered a failure in part of the victim and/or the family in the managing of emotional problems.Considering such an understanding, the survivors of the attempt tend to be seen as blameless by the society in which this stigma introduces a unique tension in the grieving process, which in certain cases can demand a clinical intervention * Periodical without an impact factor.

Comprehension of suicidal behavior
It should be noted, initially, that few studies were included in the research (six).In terms of the classification of the articles, equivalence among the types of study was observed: three were descriptive and three were literature reviews.Such findings point to the idea that researching situations of imminent risk of death, associated with controversial issues, such as the stigmatization of victims, constituted a task difficult to execute, the reason for which there are few publications in the field.In addition, such studies are extremely necessary, as much for comprehension of the problem as for the planning and implementation of effective prevention measures [17][18][19] .
Several studies are focusing on the analysis and comprehension of suicidal behavior [20][21][22] .Sena-Ferreira and colleagues 23 emphasize that the knowledge of motives that bring the individual to give up on his own life should not be a specific ac-tivity in the field of medicine.For the authors, the comprehension of this phenomenon passes through the studies of suicidology, anthropology, psychiatry and many other sciences.
It is observed that there is, currently, the tendency to consider biological factors as predominant and that the act of suicide has an important correlation with psychiatric disorders 24,25 .Mahon 26 mentions the presence of impulse disorders as a risk factor for attempted suicide, and, at the same time, other works 27,28 indicate the importance of genetic aspects involved in suicidal behavior.Bertolote and Fleischmann 29 already highlight the role of mental disturbance as one of the most important risk factors for suicide.
Sena-Ferreira and colleagues 23 indicate that, in economic terms, as many suicides as attempts result in an elevated costs for systems of social protection and health care, considering aspects such as: the Social stigma in suicidal behavior: bioethical reflections http://dx.doi.org/10.1590/1983-80422015232080loss of human capital, estimated in terms of years of life; public expenditure for health with hospital procedures; hospitalizations and treatments, and, with respect to social security, the payment of pensions and retirements by death or disability.
Despite still presenting a low coefficient of mortality by suicide, given its continental dimensions, which occupy 47% of South America 30 , Brazil is among the nine countries with the highest absolute numbers of suicide 31 .Therefore, the comprehension and study of suicidal behavior becomes a pressing necessity, since suicide attempts entail a considerable cost to the public health system and to society.

History and repercussions of stigma in suicidal behavior
It should be noted that, historically, suicide has been regarded as something disturbing; some civilizations, such as the Greco-roman, tolerated attempted suicide, yet not without some reservation, to which it may have contributed to the rise of the stigma.According to Tadros e Jolley 32 , Aristotle, in arguing that suicide weakens the economy and disturbs the gods, initiated the stigmatization of the act.Yet the authors noted the study of Barraclough, which also brings historical conceptions related to suicide.For this author, the in the Judeo-Christian tradition, the stigma of suicide is not evident until the 4 th century 33 .On this issue, Tadros and Jolley 32 cite Pritchard 34 , according to whom it was starting with Saint Augustine that the religious authority began to consider suicide as an unacceptable act in the context of Christian values -a view significantly more widespread from the 3 rd century.Thus, it is understood that the stigma of suicide was, gradually gaining momentum in Europe, so that the act itself, as well as its attempt, became a great sin, shame, and finally, crime, all under the aegis of religious tradition, which had a significant impact on this marginalization.
As for the labels associated with suicide, Tadros e Jolley 32 mention that the individuals that try or in fact commit this act are normally noted as weak, without faith, coming from families of bad character.If someone declares his suicidal thoughts and plans, it becomes the same as being mislabeled as "crazy".It is worth noting, however, that this rejection or derogatory behavior contribute little to the detection and prevention of the act of suicide.

Bioethical reflections and the stigma that involves suicidal behavior
For Daolio 35 , suicidal behavior is a disturbing theme, primarily by of the complexity of factors associated with this theme and, subsequently, by the fact that official data indicate considerable growth of suicide rates: close to one million people commit suicide annually, according to the OMS 1 .Another point made by the author 35 refers to approaches associated with suicidal behavior, spanning several schools of thought for which the causes of the phenomenon range from biological matters to those of a medical and sociological nature.Nonetheless, according to Daolio 35 , almost all these explanations are focused on the impact of the phenomenon or on the unilateral study of its causes, which disfavors the comprehension of this subject matter that is so complex and affected by numerous factors.
From such an observation emerges the importance of broadening the horizon of the research to permit the elucidation of the parallel aspects involved in the theme of suicide, as a stigma, for example.For Daolio 35 , this expanded perspective helps as much in the understanding of the factors possibly associated with behavior as the treatment of people and relatives that live with the problem.In this way, comprehending the stigma is an effective procedure for the basis of future measures of treatment.
From this panorama emerge the bioethical questions that make it possible to perceive that contemporary man is not accustomed to death and dying.It can be said that, for the current society, the finiteness and death are strictly associated with failure; because of this, it does not allow it, associating them with signs of weakness.
Accordingly, certain aspects which denote weakness, such as the case of the act of suicide, apart from being rejected, fuel the presence of comfortable labels, of which the stigma is an example.And, as it has been seen, such a stigma may bring grave consequences, as much for the subject victim of suicide or the one who was not successful in his attempt, as for the family.
The marginalization that involves suicidal behavior, it is worth noting, does not manifest itself only through the stigmas with which the society labels individuals that possess it.The unpreparedness to deal with the phenomenon is also apparent in the actions of public power, which depends on few strategies of promotion of policies or programs Social stigma in suicidal behavior: bioethical reflections http://dx.doi.org/10.1590/1983-80422015232080specifically directed at the prevention of suicides as much as the acceptance, guidance and care for individuals who attempt this act, in a way to serve them in their integrality, as well as their relatives 34,35 .
From this perspective, the stigmatization tends to become intensified, due to the minimum support from society the government spheres of the subject and his relatives -the situation that contributed to further complicate the confrontation of questions associated with suicide.As a result, it can be the triggering of new motives for the attempt, by the individual 34 , as well as new phases of disruption and conflict, for the family 35 .
From a bioethical point of view, it is possible to understand suicide as a subject of latent interest, once it affects the respect for humanity and the relative questions of autonomy 36 .In this sense, suicide, as an auto-destructive action, could correspond to an act of intentional violence that brings reflection on the fact that this behavior also reaches the very essence of our civilization and compromises the good and the future of our own humanity 35 .Such hypotheses remit to the reflection that the contemporary individual lives in a scenario many times imposed by ideologies, social and political systems that tend to inflict severe charges.In this context, the subjects, whom many times find themselves unprepared to deal with such situations, see no other option but to end their own lives 35 .
Based on this assumption, it is also necessary to reflect on the importance of ethics to the service of protection.Daolio 35 affirms that protection, in its condition of bioethics, can not be understood as paternalism, and yes as an act of a person, of public agencies and society itself, practiced in order to identify and understand those subjects considered vulnerable to the complex and varied problems that can lead to suicide.
Corroborating this argument, Schramm e Kottow 37 stress that protection, as a bioethical principle, can be understood as an act of returning the subject to total autonomy over his acts, in order to be able to decide about his future with freedom and discernment.Thereby, the bioethics conflict permeates the necessity of the stigmatized individual to be accepted and understood, permitting him and others around him the right to live together in an egalitarian way, without the label falling upon him, and, in a certain way upon his relatives, the label of "unprepared", for having decided to "flee from reality" in a difficult moment in his life.
The presence of a stigma after a suicide attempt is something indisputably distinctive, and can often trigger countless repercussions in the life of the subjects and his family, primarily in what is said in respect to living in society, since the tendency to marginalize these people is not rare, expressed by the exclusion of conviviality, labeling and sensation of depersonalization of the individual.In this context of marginalization, the event of suicide begins to take shape, for the subject, as the most representative point of his personal story.
On the issue of autonomy, Cabrera 38,39 brings up the philosophical discussions about suicide and bioethics, emphasizing that the act of suicide should be understood and recognized as the maximum manifestation of this concept, because it corresponds to the possibility of the person being able to decide about the conduction or interruption of his life.
Studies of a historical nature that punctuate that the autonomy of the suicidal act to be considered an expression of salvation of honor and preservation of morality 39 , so that this aspect, because it represents one of the philosophical perspectives related to the subject, can not be forgotten in bioethical discussions.

Final Considerations
Before the great importance of the issue, it is considered that studies like these can contribute in an incipient way to the improvement of the analysis of conduct of the people that present suicidal tendencies.Moreover, it is clear that bioethics toward the protection of human dignity should be a starting point in addressing the issue, considering the issues of autonomy and protection of the human person.
To this field of knowledge, it is contributing to the reduction of prejudice and mistaken judgments, likely to stigmatize a human being, who, taken to extreme suffering, ends up attempting to go against his own life.Every subject is characterized by his own individuality; therefore, the approach of suffering in the face of suicide ideation should have specifics that address this uniqueness.
The present study contributed to the understanding of the stigma surrounding suicidal behavior

Research article
Social stigma in suicidal behavior: bioethical reflections http://dx.doi.org/10.1590/1983-80422015232080 in a context in which it is observed that few publications correlated the themes of the stigma to suicidal behavior.Therefore, the need for further research on this topic, which is relevant to the world of sui-cidology and bioethics, is emphasized, since the reduction of stigmas can greatly facilitate the treatment of patients who experience this extreme act of self-harm.