Suicide results from a complex interaction between biological, genetic, psychological, sociological, cultural and environmental factors. The frequency of suicide among psychiatric pathologies is quite variable, with depression accounting for 45% to 70% of suicides. The association of suicide with the existence of mental illness is not consensual, with reports of rational suicides in 2% to 9% of suicide cases. It is unquestionable that the awareness of the lived experience limits the person’s condition to what it is.

To describe a clinical case on the subject and discuss the influence of cultural context in suicide.

The authors describe a case of a patient hospitalized in Psychiatry, after a suicide attempt and a consummated suicide by his wife.

The patient and his wife lived their entire lives as hermits. Although no acute psychopathology was found in the patient to justify the act, such as psychotic or depressive symptoms, dysfunctional personality traits were found, which translated into an attitude of superiority, requirement of subservience, hostility when contradicted and breaches of basic rules.

Taking into account what has been described, the authors discuss the influence of personality on the patient’s life choices and on the decision that led to the suicide attempt, as well as the suicide of his wife. A reflection is made on whether suicide can be completely independent of mental illness or whether, even in cases where rationality seems to be the causal factor, personality dysfunctionality and a profound influence of the cultural context, are present or not.

No significant relationships.

Suicide is an intriguing act of the human being. The reasons behind the violation of an instinct for survival is far from being understood. Besides, the emergence of assisted dying is raising even more questions about the concept of rational suicide, defined as a well-thought-out decision to die by whom is mentally competent.

Understand the concept of rational suicide, in parallel with suicide, by exploring the views on this debate over the years and elucidating the relationship with mental disorders, mental capacity and patient’s rights.

Literature review performed on PubMed and Google Scholar databases, using the keywords “rational suicide”, “assisted death”, “suicide”, “phenomenology”, “mental capacity” and “responsibility for life”.

The theological condemnations of suicide – as sin or crime – were put aside with psychiatric development in the last century. Durkheim was the first important precursor of the contemporary view - suicide is a form of mental illness (psychosis or depression) not compatible with rational deliberation. With the increasingly open debate on assisted dying, this vision is being tested by cases of terminally ill patients subjected to experiences that many wouldn’t choose to tolerate. Moral right to self-determination and needless suffering are examples of arguments in favor of rational suicide.

The need for an open discussion about rational suicide is raising, specifically in relation to psychiatric disorders, mainly to resolve the conflict between the duty of care of psychiatrists and the autonomy of patients.

No significant relationships.

Switzerland is among the few countries worldwide where a request for assisted suicide (AS) can be granted on the basis of a primary psychiatric diagnosis. Psychiatrists play an increasingly important role in this regard, especially when the request for AS arises in the context of suffering caused by severe and persistent mental illness (SPMI). The objective of the survey was to assess general attitudes among psychiatrists in Switzerland regarding AS requests from patients with SPMI.

In a cross-sectional survey of 1,311 German-speaking psychiatrists in Switzerland, participants were asked about their attitude to AS for patients with SPMI, based on three case vignettes of patients diagnosed with anorexia nervosa, treatment-refractory depression, or severe persistent schizophrenia.

From a final sample of 457 psychiatrists (a response rate of 34.9%) whose mean age was 57.8 years, 48.6% of respondents did not support access to AS for persons diagnosed with SPMI, 21.2% were neutral, and 29.3% indicated some degree of support for access. In relation to the case vignettes, a slightly higher percentage of respondents supported the patient's wish to seek AS: 35.4% for those diagnosed with anorexia nervosa, 32.1% for those diagnosed with depression, and 31.4% for those diagnosed with schizophrenia.

Although a majority of the responding psychiatrists did not support AS for SPMI patients, about one-third would have supported the wishes of patients in the case vignettes. In light of the increasing number of psychiatric patients seeking AS and the continuing liberalization of AS practices, it is important to understand and take account of psychiatrists’ perspectives.