Suicide prevention and management: perspective of future physicians

Abstract

Suicide has acquired progressive importance in bioethical reflections, constituting a multifactorial theme that raises important debates for medical teaching and practice, especially regarding autonomy and vulnerability. To investigate the topic in the field of medical education, this study sought to understand the opinion of medical students on the subject. Data were collected by a semi-structured questionnaire applied to 188 students (all genders) enrolled in a public state university. The findings reinforce the importance of personal and academic preparation through interventions with people at risk of suicide. However, the topic of suicide is still little discussed during the training of future physicians, particularly considering the importance of educational and preventive actions in this scenario.

Suicide; Students, medical; Education, medical; Bioethics

Resumo

O suicídio tem adquirido progressiva importância nas reflexões bioéticas, constituindo temática multifatorial que suscita importantes debates para o ensino e a prática médica, em especial no que se refere à autonomia e à vulnerabilidade. Com o intuito de problematizar o assunto no campo da educação médica, este estudo pretendeu compreender a opinião de acadêmicos do curso de medicina acerca do tema, por meio de questionário semiestruturado aplicado a 188 acadêmicos de ambos os sexos, matriculados em universidade pública estadual. Os achados reforçam a importância do preparo pessoal e acadêmico em intervenções junto a pessoas em risco de suicídio, entretanto a visibilidade dessa temática na formação de futuros médicos ainda é um desafio, particularmente quando se considera a importância de ações educativas e preventivas nesse cenário.

Suicídio; Estudantes de medicina; Educação médica; Bioética

Resumen

El suicidio ha ganado espacio en las reflexiones bioéticas al ser tema multifactorial de debate para la enseñanza y la práctica médica, sobre todo en lo que se refiere a la autonomía y la vulnerabilidad. Para tratar este tema desde el campo de la educación médica, este estudio tuvo como objetivo conocer qué piensan los estudiantes de medicina sobre el tema; para ello se aplicó un cuestionario semiestructurado a 188 académicos de ambos sexos, matriculados en una universidad pública estatal. Los hallazgos destacan la importancia de la preparación personal y académica en las intervenciones con personas en riesgo de suicidio, sin embargo, el planteamiento de este tema en la formación de los futuros médicos sigue siendo un desafío, particularmente cuando se considera la importancia de las acciones educativas y preventivas en este escenario.

Suicidio; Estudiantes de medicina; Educación médica; Bioética

Motivations for suicide are intertwined with a set of complex factors, including the social and cultural setting, as well as economic and psychological factors ¹. In the field of health, this subject is discussed as a kind of self-inflicted violence, especially due to its close relationship with affective disorders, currently considered to be triggers or enhancers of psychological distress and risk factors for its occurrence ².

Given its complexity, suicide has been the object of numerous interdisciplinary studies and research, involving sociology, law, psychology, and medicine ³. These studies aim to produce answers about suicide, including understanding its causes and correlations, as well as promoting measures to cope with the problem ³.

In this context, bioethics, as an interdisciplinary field that combines biological knowledge with the reflection on human values, has increasingly problematized the topic of suicide, focusing on issues related to autonomy and vulnerability ⁴. Suicide encompasses controversial themes and relevant ethical and legal issues concerning both individual and collective health, bringing out complex, disturbing, and not always consensual reflections on the right to die: Should people be free to decide how they wish to die? Who gets to make decisions about the right to life? Is it ethically acceptable to help someone die? Should suicide be accepted as the full manifestation of the individual’s autonomy ⁵?

Authors who defend the protection of life must consider the various motivations and expressions of suicide, which raises concerns and doubts regarding vulnerability and preventive actions. Suicide is not an isolated act, but rather the endpoint of a sum of factors, including the (questionable or not) right to freely decide on one’s own destiny ⁴,⁵.

Prevention actions seek to stimulate the individual’s full autonomy in the face of threatening situations, so that they are able to decide consciously and freely, reversing their own situation of vulnerability. However, people seldom express their weaknesses and often suicide becomes not only an expression of suffering, but its solution ⁴.

Despite advances in considering suicide a health issue, the stigma surrounding this topic still persists, fueled mainly by the prejudice that individuals who experience suicidal ideation are weak, faithless, or come from bad nature families ⁶. Such stigmas make coping with suicide difficult, resulting in discrimination and isolation, which can contribute to the planning and occurrence of new attempts at self-aggression and the development of other morbidities, such as a greater predisposition to using psychotropic substances ⁵.

Unfortunately, the difficulties in effectively facing this issue finds echo in the performance of healthcare providers, hindering its identification and prevention ⁵, culminating in a moral rather than technical debate. Besides, many professionals may face problems in dealing with a situation for which they have not been properly trained, causing frustration, impotence, and anger, especially when personal feelings are not properly managed.

Despite existing data on the worldwide panorama of suicide, the World Health Organization (WHO) ⁷ believes that the numbers are underestimated by up to four times due to underreporting or lack of reporting, especially in African and Middle Eastern countries. Prejudice on the topic, still considered a taboo in many countries, as well as substitution for other causes of death, such as car accident, drowning, accidental poisoning, and “undetermined cause,” contribute to this information gap ⁸,⁹.

In absolute numbers, Brazil is among the nine countries with the highest number of suicides, revealing the topic as a serious problem, with high costs to the health system, not to mention the number of lives lost ⁵. Notification of attempted or actual suicide is compulsory within 24 hours from the time of care in the public or private health network for monitoring and following up on the cases treated in these services, aiming at preventing and coping with new occurrences ¹⁰. Nonetheless, keeping epidemiological data updated still seems difficult, largely because not every attempt is properly identified as such, which would possibly increase the number of cases registered in the national monitoring system ¹¹.

Given the importance of the topic for the field of health, suicide has also gained notoriety in the medical field. Increased cases among medical students, a fact more evident in studies on academic stress, as a result of the extensive study routine, contributes to this interest ¹². Despite intensification of preventive actions and dissemination of support strategies, and the existence of some manuals and intervention protocols, many professionals feel powerless, not knowing how to act in such situations ¹³.

In medical practice, the physician’s communication skills contribute to a more adequate intervention in the face of suicide risk, but they should know how to identify, approach, manage, and refer to specialized services. Contrary to recurrent perceptions in the social imaginary, suicide is preventable, but effective actions depend directly on the type of approach taken.

Professionals in many health care services lack skills to address this kind of situation, an unpreparedness that results from a markedly biomedical academic education and training, with little appreciation of subjectivity, and the low level of training of active technicians ². Treating suicide with the seriousness it requires is not only a necessity, but an ethical imperative of healthcare providers in the face of the countless situations that make human existence fragile and vulnerable.

As a strategy to foster debate in medical education, this study sought to evaluate the opinion of medical students attending a state public university in Brazil on the topic, including their personal and academic attitudes toward this issue.

Method

This descriptive, cross-sectional, exploratory, quantitative and qualitative study used a convenience sample of students enrolled in the medical program at the State University of Pará (UEPA) who agreed to participate by signing an informed consent form. The research was approved by the Research Ethics Committee.

Our study protocol included a semi-structured questionnaire with open and closed questions, of which some were formulated by the authors and others were adapted from the Suicide Behavior Attitude Questionnaire (SBQA) proposed by Botega ⁸. Questions were structured to understand the students’ opinions, experiences, and personal attitudes toward suicide, including their preparedness to intervene with individuals facing this process.

Data were mainly analyzed by descriptive statistics, using Microsoft Excel 2010 to present the results in tables. We also performed a qualitative investigation using Bardin’s content analysis method, which involves systematizing, analyzing, and categorizing the answers to open questions.

Results and discussion

In total, 29 (15.4%) first-year, 35 (18.6%) second-year, 34 (18.1%) third-year, 31 (16.5%) fourth-year, 28 (14.9%) fifth-year, and 31 (16.5%) sixth-year students participated in this study. Most were women (53.7%) between 20 and 24 years old (56.3%)—23.9% were below this age group and 19.8% above.

As for religion, 75.5% of students reported having a denomination: most were Catholic Christians (48.8%), followed by Protestant Christians (12.8%) and Spiritist (9%), a finding similar to that of a study conducted with medical students in Southeastern Brazil ¹⁴ Table 1 summarizes information on how students perceived the religious influence on their decisions.

Table 1
Relationship between medical students’ religion and the importance of religiosity in their decisions

Religion of students	Importance of religion in decision-making
	Irrelevant	Unimportant	Neutral	Important	Very important	Total
Catholic Christians	7.7%	14.3%	30%	35%	13.2%	91 (48.4%)
Protestant Christians	–	8.3%	8.3%	16.7%	66.7%	24 (12.8%)
Spiritist	–	5.9%	17.6%	47%	29.4%	17 (9.0%)
Other religion	–	20%	10%	60%	10%	10 (5.3%)
Agnostic	40%	26.7%	20%	13.3%	–	15 (8.0%)
Atheist	91%	9%	–	–	–	11 (5.9%)
Not declared	45%	20%	60%	5%	–	20 (10.6%)
Total	17%	14.4%	22.2%	28.3%	18.1%	188 (100%)

A total of 46.4% of students considered religion an important or very important factor in decision-making, but 36.7% considered it unimportant or irrelevant. A study with physicians in the United States found similar results ¹⁵. Religion is more important in decision-making among Protestant Christians, followed by Catholic Christians, Spiritist, and practitioners of other denominations.

The influence of religious beliefs on how one’s view suicide is important, since religion can interfere, even if unintentionally, in the physicians’ point of view and consequently in their clinical approach. Monotheistic religions, for example, value the principle of the sacredness of life, thus, suicide is often considered an attack on God ¹⁶. In other words, decisions about ending life do not belong to the individual for life is a sacred good.

Autonomy

When asked whether suicide should be understood as an expression of freedom and autonomy, most students strongly or partially disagreed with the statement (62.2%), 24.5% strongly or partially agreed, and 13.3% took no particular stance. Suicide as an expression of individual autonomy is indeed a controversial issue, since individuals are not necessarily independent in their choices ¹⁷.

Many who idealize it do so for unconscious motivations and as an attempt to cease some type of preexisting suffering. In general, the impossibility of facing external or internal pressures can affect self-determination ¹⁸ and rationality ¹⁹, intensifying suicidal ideation.

A very widespread perspective in the medical field is based on the close association between suicidal behavior and mental disorders, as variables that increase one’s vulnerability and are present in most cases ²⁰. But the topic raises debates among those who defend the right to take one’s own life as an act of freedom and autonomy, as long as it does not involve the lives of others ²¹. In Brazil, attempts or suicides are not typified as crimes, however, Article 122 of the Penal Code considers “inducing, instigating, or assisting in suicide or self-mutilation” a crime ²².

Regarding the statement “life is a divine gift and only God has the right to intervene in it,” 67 (35.6%) students strongly or partially agreed, of which 52 were Christians, five were Spiritist, six practiced other religions, three were atheists/agnostics, and only one had no religion. Among students who believed in the sacredness of life, 79.1% considered religion important or very important in decision-making.

Although most students were religious, 47.9% disagreed with the statement, of which most were atheists/agnostics or had no religion, but 1/3 were Catholic Christians.

Suicide in medical education

Are physicians prepared to intervene?

The need to breach medical confidentiality in case of suspicion or confirmation of suicide attempt is an essential aspect to be considered in medical interventions, since healthcare providers must report it compulsorily. Among all students, 64.7% strongly or partially agreed, 16.6% remained neutral, and 18.7% strongly or partially disagreed with breaching medical confidentiality. Such findings must be valuable, because, even if participants are still undergraduates, identifying situations of compulsory reporting is a topic to be addressed since the first years of the course, including in subjects related to medical ethics ²³.

Studies show that most individuals who have attempted suicide had a medical consultation prior to the event ²⁴, which begs the question: Are professionals able to listen to their patients and, consequently, identify in their narratives indicative signs of suicidal ideation? This is not simply a matter of breaching confidentiality, but of offering help alternatives, including referral to specialized services.

Care and communication

About 48.1% of students strongly agreed, 35.3% partially agreed, 10.2% remained neutral, and 6.4% strongly or partially disagreed with the statement “I feel willing as a person to help someone at risk of suicide” (Table 2). However, the desire to help does not always materialize in concrete actions due to prejudice and lack of knowledge related to suicide. Representations associating suicide with failure, lack of faith, and, in some cases, “bad character” persist in the social imaginary, making many people unwilling to offer help ⁵.

Table 2
Medical students’ attitudes toward suicidal ideation

	I strongly disagree	I partially disagree	I neither agree nor disagree	I partially agree	I strongly agree
“I feel willing as a person to help someone at risk of suicide”	2.7%	3.7%	10.2%	35.3%	48.1%
“I feel willing as a future physician to help a person at risk of suicide”	–	1.6%	4.8%	28.7%	64.9%

Studies show that suicide is a process that includes ideation, planning, attempt, and consummation of the act ²⁴. For those who practice active listening in the physician-patient relation, a simple gesture can be more significant than words. Thus, when asked about their professional future and their intention to help a person at risk of suicide (Table 2), about 64.9% students strongly agreed, and none strongly disagreed with the statement.

A study by Magalhães and collaborators ¹³ with medical students also observed positive attitudes toward the topic, especially among students in the post-clinical period due to greater knowledge and, consequently, less prejudice toward patients. Such positive stance is extremely important in medical education, as it stimulates personal skills and the proposal of more effective interventions.

Regarding the statement “I do not think it is correct to ask questions about suicidal ideation, because it can encourage the patient,” 54.3% of students strongly disagreed, 30.3% partially disagreed, and 9% remained neutral. Despite the fear of approaching issues related to suicidal ideation, as this topic is deemed “uncomfortable” by many people, talking about it is essential, especially because many suicidal individuals contacted a physician before committing the act ²⁴.

Final considerations

Suicide in the context of bioethics raises numerous questions, many of which remain unanswered. However, the prejudice and stigmas attached to this topic need to be faced so that it acquires the visibility it deserves. Thus, medical education must include suicide as a subject of discussion so that future professionals are able to identify risks and intervene early in the delicate task of caring for human lives.

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• Approval CAAE 91076518.8.0000.5174

Publication Dates

• Publication in this collection
  20 Feb 2023
• Date of issue
  Oct-Dec 2022

History

• Received
  9 Sept 2021
• Reviewed
  22 Sept 2022
• Accepted
  25 Sept 2022