An observation was made the other day, in oncology out-patients, as we were debriefing in the serendipitous way doctors do. The observation was made that one can imagine certain people committing suicide (Dr. Salomon Stemmer, personal communication).

We tried to imagine who would contemplate suicide: patients, colleagues or indeed self. The question that eventually formed was: what are the characteristics of the individual that suggest suicidality?

• There are those that when the purposelessness and absurdity become too great will consider suicide.

• There are those who say the pain is not worth it (life).

• There are those whose hope has transmogrified to hopelessness.

• There are those who might consider it but think it to be a mortal sin.

• There are those who consider it but put it off until things become worse.

• There are those that surprise us.

Animals do not contemplate suicide. Animals do not do it. Mass deaths of whales, lemmings and birds are not the equivalent of suicide. They are driven by an unconscious biologic drive, or simply mistakes. Animals may be aware they are dying and seek a place of solitude to turn up their paws. However, animals do not have the depth of consciousness (or even unconscious) to know they can end their own lives.

Albert Camus noted in 1955 in his essay Absurdity and Suicide (Camus, 1955): “There is but one truly serious philosophical problem and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy. All the rest — whether or not the world has three dimensions, whether the mind has nine or 12 categories — comes afterwards. These are games; one must first answer … All healthy men having thought of their own suicide, it can be seen, without further explanation, that there is a direct connection between this feeling and the longing for death.”

The thought of suicide springing up as it does from the darkness, is inextricably associated with the appeal of death. (So it is with depression.) Many poets and playwrights have written about the relief of death (Wein Reference Wein2010). John Donne in his Holy Sonnet X:

Camus seems to suggest that the thought of suicide comes after the “longing for death.” The thought follows the feeling, even though the thought appears to well-up unbidden, yet purposively from the great unknown. Nevertheless it is certain that the idea — nay the passion — for suicide is a dense mixture of heart and mind. It is a thought that latches then insinuates itself into the most private of conversations, that between I and me. It is a thought that can offer great relief. Remember Cathy in Steinbeck's master work, East of Eden (Steinbeck, Reference Steinbeck1952)? Whenever life became difficult she held, for reassurance, a vial of poison that hung around her neck, until the time came to use it.

Casting into relief Camus' observations against the thought-lessness of animals, one is left to consider that the clue to suicidality is self-reflection. Is this the worm in the heart? That is, a person who starts to reflect on himself — and not deny — will start thinking about life, its problems, whether it is worth the effort, the absurdity of make-believe-meaning in a meaningless world, and then non-life, and if there is a particular alignment of the planets and stars, then about suicide. It is ineluctable. We can never see our own eyes, the portals to our putative soul, except in reflection. However I am the only person capable of examining my inner workings. Insight starts when the little voice in my head begins talking to me.

Socrates thought that the unexamined life is not worth living, and of course he meant an examination of ones own life. Self-reflection though, appears to be not without risk.

Is the risk worth it?