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Reshaping the Ethics of Suicide Prevention: Responsibility, Inequality and Action on the Social Determinants of Suicide

Reshaping the Ethics of Suicide Prevention: Responsibility, Inequality and Action on the Social... Abstract Value judgements in research and political decision-making that exclude evidence for the social determinants of suicide suggest that evidence is not sufficient on its own to guide policy and practice, and that there is a lack of conceptual clarity with regard to decisions relating to the prioritization of problems, the allocation of resources, the translation of research into practice, as well as questions of responsibility for suicide prevention. In this work I seek to broaden conventional ethical debate about suicide through the use of public health ethics frameworks. I argue that despite espousing a public health approach, current suicide prevention strategies are based largely on individual-level theorizing. This emphasis on the individual works to responsibilize individuals and communities for suicide prevention and directs attention away from public policy and systemic inequities. Given continued high rates of suicide, especially among disadvantaged social groups and communities, comprehensive government action is required to address the social and political determinants of suicide. Normative justification for action in realizing these ends is critical. I conclude by proposing one practicable form of action to make values and value judgements in suicide prevention explicit so that alternative forms of ethical and political recognition and responsibility are acknowledged. Introduction For most of the 20th and well into the 21st century ethical discussion of suicide in the West has been largely confined to the margins of suicidology (Cardinal, 2008; Battin, 2015). Broadly conceived as the science of suicide and suicide prevention, suicidology has become a powerful social practice delineated by specific normative, epistemological and methodological commitments that privilege biomedicine (Fitzpatrick et al., 2015). Consequently, with few exceptions, most extant work on the ethics of suicide is based on an individualistic conceptualization of suicide. This individualistic orientation is consonant with the dominant intellectual and political culture of formalized suicide research and prevention, but also with predominant views in bioethics that have traditionally prioritized individual over population interests. A considerable body of work, for example, has directed attention toward the norms of care governing the management and treatment of suicidal patients and, in particular, the use of coercive, invasive or emergency interventions and their implications with regard to the rights, interests, values, dignity and capacity of persons who are suicidal (Sontheimer, 2008; David et al., 2010). Ethical issues associated with suicide research have also been the focus of some discussion (Stanley, 1986; Mishara and Weisstub, 2005; Lakeman and Fitzgerald, 2009). These works also draw heavily on concepts and language inherited from clinical ethics and research ethics including confidentiality, duty of care to research participants and disclosure of risk. Despite this focus on the individual and the framing of suicide as a major preventable mental health problem, it is widely accepted that a range of social, cultural and political factors contribute to suicide. Adverse economic conditions, insecurity of employment, trauma, abuse, discrimination, poverty, inequality, social isolation and exclusion are all factors that put persons at risk of suicide (World Health Organization, 2014). Subsequently, public health organizations, academics and advocates have long highlighted the need to acknowledge and address the social determinants of mental health and suicide (Stuckler and Basu, 2013; Mills, 2014). Yet, despite broad consensus on the importance of the social determinants of mental health and the provision of evidence-based recommendations to address them (Commission on Social Determinants of Health, 2008), suicide prevention frameworks responsive to this emerging knowledge are yet to be fully developed. Current population-based interventions that aim to increase access to mental health services through mental health literacy and community awareness programs, for example, continue to operate within an individualistic framework aimed at identifying psychological and behavioral risk factors. The understanding that suicide is strongly influenced by social and political determinants and that political action has increasing relevance to suicide prevention policy gives rise to a number of ethical issues outside the parameters of traditional bioethical approaches to suicide (Dawson and Silva, 2009). Because suicide raises concerted moral and political debate about the underlying causes of suicidal distress and the action that is needed to address this important issue, ethical reasoning is a critical political force in suicide prevention and has noticeable effects on the way suicide is constituted as an ‘issue’ and the political claims made by public institutions, professionals and user groups as justification for action. Narratives of suffering, trauma and misfortune draw our attention to the plight of farmers, youth, Indigenous and First Nation communities and other at-risk populations in an effort to compel policymakers to action. The bases for suicide prevention is therefore underpinned by a set of values for determining what is right and good, and how suicide prevention should be implemented to ensure that it reflects the needs and values of those that it is intended to serve. A central problem of suicide prevention policy and practice, however, is its conceptual vagueness regarding the ethical bases for decisions relating to, for example, the prioritization of problems, the allocation of resources, the translation of research into practice, as well as conceptualizations of risk and responsibility for suicide and its prevention. And while many local and national suicide prevention policies and strategies promote ethically relevant concepts such as social responsibility, empowerment, equality, vulnerability and care (Australian Government Department of Health and Ageing, 2000, 2007), they are rarely defined in any detail or with reference to existing ethical theory or empirical evidence. These concepts, moreover, are embedded in social and political contexts in which relations between the state and its citizens regarding risk and responsibility for suicide are constantly being redrawn. The above concerns point to the importance of broadening the traditional focus of ethical approaches to suicide to include discussion of suicide and its prevention as a public health issue. Given this is a largely unexamined area in the contemporary context, this work does not aim to provide a comprehensive ethical analysis of the many and varied activities that currently make up suicide prevention practice, but rather to direct attention to a number of its salient features to stimulate ethical reflection and to expand the current parameters of ethical debate. To begin, I establish suicide as a public health issue and discuss the advantages of public health ethics approaches for examining the distinct moral features of suicide prevention at a social and political level. Following this, I describe current approaches to suicide prevention that increasingly emphasize the need for intersectoral collaboration and multilevel approaches. Although the documents that are the focus of analysis in this work derive primarily from the Australian context, they reflect current trends in international suicide prevention practice in relation to evidence and the eschewal of the socioeconomic determinants of suicide. This strong bias toward understanding suicide as individual rather than societal, I argue, has led to the fostering of unjust relations of responsibility for suicide prevention that create a number of potential burdens and harms for individuals and communities, and I use the example of farmer suicide to illustrate this. In closing, I make a case for the use of specific policy and advocacy tools as a way of redressing existing inequalities and enhancing whole of government systems to address the social and political determinants of suicide. Suicide as a Public Health Issue and the Role of Public Health Ethics Recent work in public health ethics has identified the shortcomings of dominant individualist ethics frameworks for examining public health (Jennings, 2007; Baylis et al., 2008; Dawson, 2011). What these works hold in common is the view that health is significantly different when considered from a public health as opposed to a clinical or individual perspective, and that clear articulation of the aims and methods of public health is required prior to analysis of public health ethics issues (Jennings, 2007; Dawson, 2011). There are three central issues I would like to briefly touch upon in establishing suicide as a public health issue. First, because public health is primarily focused on the health of the population or community and not just with the health of individuals (Dawson, 2011), it takes into account the ways in which membership in particular social groups shapes the ways that persons are socially, politically and economically situated with regards to systematic privilege or disadvantage, how these impact upon health status and accordingly, the goals and activities of public health (Baylis et al., 2008). Writing on the role of public health and public health ethics in suicide prevention, Dawson and Silva (2009) contend that because many of the causes of suicide extend beyond individual behavior to the population level (for example, injustice, discrimination, mental illness) and relate to membership of various social groups and communities (for example, Indigenous; Lesbian, Gay, Bisexual, Transgender, Intersex, Queer; those in the criminal justice system) they can also be addressed through population-based preventive strategies. Second, public health activity is directed toward preventing and reducing harm at a population level and not just providing treatment (Dawson, 2011). This concern with the health of the population or community is evident in such preventive activity as the responsible media reporting of suicide; means restriction; and school-based and community peer-support, education and awareness programs, as well as those targeting groups at high risk in the community. Such interventions derive from inferences made regarding population risks and that programs will reach these individuals and result in fewer suicides. Third, because the contexts in which people live their lives may limit or expand the opportunities for them to be healthy and to make decisions about their health, the attainment of many public health goals is beyond the individual and requires collective action (Jennings, 2007; Baylis et al., 2008; Dawson, 2011). Because such interventions usually require action at a social and political level, moral justification for them can be especially demanding (Jennings, 2007). Consideration of the nature, aims and methods of public health practice in the field of public health ethics has led to increasing concern over the inadequacy of prevailing liberal medical ethics frameworks for thinking about public health ethics issues. The focus on individual autonomy, rights and interests that underpin these approaches are considered insufficient for the ethics of public health where concerns with collective interests are of greater importance (Jennings, 2007; Kenny et al., 2010). One of the primary tasks of recent work in public health ethics, therefore, has been the cultivating of more suitable conceptual and analytic frameworks able to capture the distinctive moral features of public health practice and public well-being, and to assess the systematic inequalities that undermine public health to guide action at the social and political levels to address them (Rogers, 2006; Kenny et al., 2010). Current ‘Best Practice’ in Suicide Prevention Suicide prevention in Australia and other high-income countries draws on international evidence that supports the use of multicomponent interventions. While differences exist with regards to the number and choice of core components that comprise local and national suicide prevention strategies, a number of best practice activities have evolved to guide policymakers and practitioners in their development (World Health Organization, 2014). Evidence for multicomponent interventions is positive, with their implementation associated with short-term decreases in suicide and suicidal behavior in several European trial regions (Székely et al., 2013). Despite existing evaluations showing limited efficacy for several individual system components such as community awareness, gatekeeper training and school-based prevention programs (Mann et al., 2005; Scott and Guo, 2012; Caine, 2013), proponents argue that it is the strong synergistic effects of these multi-tiered strategies that account for their overall effectiveness (van der Feltz-Cornelis et al., 2011; Székely et al., 2013). Some caution should be exercised when assessing these claims, however, particularly given that research has been unable to identify which of the individual system components might be most relevant, and that there has been no research examining the important role of other mediating factors—including culture—on outcomes, or assessment of the long term-term influence of these interventions on suicide rates. As they are currently conceived, multicomponent approaches focus almost exclusively on intersectoral collaboration and the coordination and integration of mostly existing intervention strategies as opposed to considering the deeper system structures that exert strong influence on suicide prevention practice such as research and the policymaking process. Discussion of the social and structural determinants of suicide and preventive strategies that focus on addressing broader political, economic and social issues also remain outside the system boundary. In its recent report, Preventing Suicide: A Global Imperative (WHO, 2014), the World Health Organization made no mention of the importance of addressing social determinants in its list of typical components for the creation of comprehensive national suicide prevention strategies. This is exemplified in current ‘systems’ approaches in Australia that deliberately eschew the social determinants of suicide in favor of short-term actions aimed at having a swift positive impact on reducing suicide rates in accordance with national and global targets (NHMRC Centre for Research Excellence in Suicide Prevention and Black Dog Institute, 2015). Given these assessments, it would be reasonable to expect that the deliberate exclusion of the social determinants of suicide within multicomponent approaches reflects a general lack of evidence with regard to their significance. Yet the longstanding and pervasive body of evidence that shows a relationship between suicide and socioeconomic factors, and the emerging body of evidence from Europe that has shown the benefits of non-health sector policy on reducing unemployment-related suicide does not support this position (Taylor et al., 2005; Milner et al., 2012; Stuckler and Basu, 2013). While the coordination of activities is important given the siloed nature of suicide prevention, the primary challenge for suicide prevention moving forward is not solely a lack of evidence for what works as is often presumed, but from a set of value judgements about research evidence and political decision-making that hinder action on the social determinants of suicide. The narrow ‘evidence-based’ framing of policymaking has been shown to be inconsistent with the way it actually occurs (Black, 2001; Greenhalgh and Russell, 2009). In the case of transformative policy change, the presence of research evidence alone may not be sufficient justification for change, especially when the proposed changes challenge the set of widely held philosophical beliefs about the role of government in matters relating to broader mental health determinants such as racism, poverty and violence (Gostin and Powers, 2006; Crammond and Carey, 2017). In such cases, ethical, rather than evidence-based, arguments may be of significantly greater importance to the successful realization of policy change (Crammond and Carey, 2017). The multidimensional character of suicide ‘risk’ leads us to question the system of shared responsibility for suicide prevention and the ethical implications of seeking to prevent suicide without addressing the root causes of poor mental health, distress and suicide (Dawson and Silva, 2009). Essential treatment of mental health problems should not, after all, be conflated with suicide prevention as a public health concern (Caine, 2013). Following this, we might ask what harms occur if public health research findings are not translated into suicide prevention policy and no benefits accrue from this research (Kass, 2001). These arguments raise a set of challenging questions about how different forms of responsibility for suicide prevention are envisioned and enacted within current policy and practice. In the remainder of this article, I outline the assumptions and principles of responsibilization that underpin contemporary suicide prevention policy and practice, and in doing so, make an argument for why those working to prevent suicide should be concerned about the harms caused by the failure to act on the social determinants of suicide, and the kinds of political and collective action needed to address them. Configuring Relations of Responsibility for Suicide Prevention Responsibility for suicide prevention extends across multiple domains. These include the suicidal or previously suicidal person’s responsibility to him or herself and to others to minimize risk by seeking help and complying with treatment recommendations. Other forms of responsibility are evident in policy documents and interventions directed toward families, communities, schools, sporting clubs, workplaces, media and health and community professionals and organizations. These broadly stipulate the importance of community ownership and responsibility in preventing suicide, although in practice what this means is unclear. In most cases it is used to establish the foundation for embedding suicide prevention activities, namely, education, gatekeeper training programs and responsible media representations within the whole of community. Responsibility is also attributed to mental health professionals and institutions that have a significant duty in caring for persons who are suicidal. Another form of responsibility is that which has been taken up by organizations engaged in suicide and mental health education and promotion. Responsibility for suicide prevention is also assumed by federal, state and local governments who oversee funding commitments, outcomes and specific policy directions (Australian Government Department of Health and Ageing, 2007). These relations of responsibility are characterized by different reciprocities of trust, care, accountability and obligation and, therefore, require closer analysis of what competing responsibilities entail (Trnka and Trundle, 2014). Notions of building individual and community strength, resilience and capacity—so often evident in suicide prevention policy—illustrate how ideals of responsibility are enmeshed within the logics of neoliberalism and the set of broader, complex political and economic practices shaping contemporary social relations (Shamir, 2008; Trnka and Trundle, 2014): Resilience is the ability to bounce back after experiencing trauma or stress, to adapt to changing circumstances and respond positively to difficult situations. It is the ability to learn and grow through the positive and the negative experiences of life, turning potentially traumatic experiences into constructive ones. Being resilient involves engaging with friends and family for support, and using coping strategies and problem-solving skills effectively to work through difficulties (Australian Government Department of Health and Ageing, 2007). While not discounting the need for resilience approaches, we should be cautious of their position of dominance in the suicide prevention field (Harper and Speed, 2012). Processes of individualization and responsibilization have been widely linked to neoliberal ideals including the decline in government spending on the collective health and well-being of citizens, and a strong bias toward understanding principal mental health challenges as individual rather than societal (Raphael et al., 2008; Teghtsoonian, 2009). Therefore, while the obligation of mental health services to provide appropriate and continuing care for suicidal individuals or those at risk presupposes a duty of care to the welfare of others, this commitment to care exists in dialogical relationship with neoliberal ideals of personal and interpersonal responsibility and accountability that directs attention away from public policies and systemic inequities (Teghtsoonian, 2009; Trnka and Trundle, 2014). The discursive strategies visible in suicide prevention communication campaigns that presume suicide to be driven by individual pathology, and that in turn work to responsibilize individuals, families, workplaces and communities for suicide prevention, pose a number of potential burdens and harms. Over the past decade, various studies have examined the self-management techniques performed by individuals to reduce harm and risk and to preserve their mental health, and how these enactments are aligned with neoliberal policy orientations and, in particular, the framing of mental ill health and distress as originating in individual bodies and minds (Teghtsoonian, 2009; Trnka and Trundle, 2014). In the case of attempted suicide, enactment of the responsibilized individual is further entangled in complex dynamics around moral responsibility where the assuaging of individual blame and censure is bound inextricably with practices of accountability that construct one as responsive, prudent and resourceful in managing further conduct. Here, the interrelationship between mental health and suicide literacy, and the provision of appropriate and continuing clinical care for suicidal persons or those at risk, are presented as two sides of the same coin. In this view, the provision of information to individuals and collectives (families, workplaces and so forth) can enhance individual knowledge and skills, helping people to make better decisions regarding their own and others mental and emotional well-being and the types of services and supports required to assist them (Teghtsoonian, 2009). This sleight of hand works not only to transfer responsibility to individuals and collectives, suggesting that risk is somehow under individual control, it explains people’s avoidance of clinical services as a result of ‘poor mental health literacy’, ‘negative beliefs’ and ‘stigma’ rather than dissatisfaction with, or the inappropriateness of, existing services (Taylor et al., 2009; Mills, 2014). This ethic of self-care is manifested in various self-management practices such as disclosing and controlling negative emotions and reframing understandings of suicide and distress—practices that have been shown to pose additional individual and social burdens (Brownlie, 2012; Fitzpatrick, 2014). Families, workplaces and communities are important sites of support, and mental health education and training programs make the assessment of other’s thoughts, emotions and actions a key task in helping them to identify and reduce risk. Such programs have focused on positioning emotional disclosure as beneficial, and consequently, eliciting and hearing personal stories of emotional or psychological distress is encouraged. Yet such approaches may impose undue burdens on particular segments of society through the obligating of peers to promote access to care, and the burden of dealing with challenging issues such as substance use, interpersonal violence, sexual identity and family disintegration (Kalafat, 2003). The kinds of surveillance and assessment techniques necessitated by these approaches may also undermine conditions of trust and reciprocity between persons. The emphasis on assessment and referral can appear paternalistic through its prioritizing of risk containment over personal relationships, especially when supportive relationships based on unconditional acceptance, understanding and empathy may be of far greater importance (Brownlie, 2012). Practices of care are enacted through intimate face-to-face relationships and between collectivities, and the above practices do not necessarily preclude the provision of compassionate care (Trnka and Trundle, 2014). My focus here is not on specific care practices per se, but rather, how certain kinds of responsibility are nourished and legitimated via these practices and in dialogical relationship with liberal democratic values, goals and orientations. The view of responsibility that underpins such approaches is of people acting in a way that presupposes the needs and interests of others. Moreover, in operating primarily through a moral language of suffering and compassion, other forms of expression and social relations are masked, with perceptible effects for public and private practices (Fassin, 2012). The move to contextualize practices of responsibility to show how individuals and communities are nested within multiple relations of dependency, reciprocity and obligation shifts attention to the moral and political values upon which particular kinds of responsibility are founded and legitimated (Trnka and Trundle, 2014). A good example of this, and how uneven and conflicting relations of responsibility can impose additional harms and burdens on individuals and communities, is the issue of farmer suicide. Uneven and Conflicting Relations of Responsibility in Farmer Suicide As with other health and social problems that are shaped by economic, political and environmental factors, responsibility cuts across multiple domains (Trnka and Trundle, 2014). One example of intersecting responsibilities is the issue of farmer suicide. In India, farmer suicide has become increasingly politicized with high rates of suicide in some regions coming to symbolize, to a greater or lesser extent, a precarious agrarian existence in the context of industrial modernization, neoliberal reform and the failure of the nation state to protect its agrarian population (Münster, 2012). Because farmer suicides are not self-evident types of death but become reified through discourse and the classificatory practices of the state, the politicized nature of suicide in India has had a significant impact on policy and program design, as well as providing farmers with a frame for comprehending their distress and the effects of large-scale economic and political processes on their lives (Münster, 2012). While this has inspired farmers to activism and collective action, and led to the introduction of general programs aimed at ameliorating debt and generating employment for rural workers, the extent and justification for state and corporate responsibility are contested. Recognition of the socio-political and economic determinants of suicide does not necessarily translate into structural change at the state level. Indeed, even in those contexts where economic and political factors are acknowledged, interventions often remain focused on individual-level factors due to the incapacity of services to engage with these larger problems on the ground, the subsequent reframing of polyphonic presentations of distress through a dominant psychiatric nosology, as well as conflicting views on the role of government (Mills, 2014; Crammond and Carey, 2017). In Australia, environmental and political issues affecting farmers’ health and well-being such as drought, agricultural subsidies, animal welfare and land and water use and management have also been problematized through a mental health lens. The solutions put forward, again, operate primarily at the individual level. For example, one of the main areas of action put forward by the NSW Farmers Mental Health Blueprint is to enhance the resilience of individuals and families to manage the pressures of life and work on the farm (Australian Centre for Agricultural Health and Safety, 2016). These attempts to responsibilize farming communities are evident in discourses and practices that not only encourage individuals to access appropriate welfare and social support, but that emphasize the importance of management skills development. In this view, farmers are urged to calculate the potential impacts of business pressures on their health and well-being and to consider other options such as capital investment, more efficient practices or to ‘just walk off the land’ (Scarr and Anthony, 2011; Bryant and Garnham, 2014). In certain contexts, such moves toward responsibilization are considered unjust. A recent study of Australian wine grape growers, for example, highlighted the perceived injustices experienced by growers as a result of state and corporate intervention in the wine industry (Bryant and Garnham, 2013, 2014). Such perceptions of injustice were the potential basis for distress, but also for expressions of moral outrage at the violation of loyalty, trust and respect in social and economic relations between grape growers, wineries and the state. The connection between farmer distress and emotions such as anger and contempt exemplifies cognitive and cultural conceptualizations of emotion in which beliefs and moral judgements have a central role (Harré, 1986). Emotions of shame and guilt were common to farmers’ experiences of distress and closely bound with perceptions of self-worth and attributions of personal responsibility. However, farmers also apportioned blame for their troubles to the government’s dismantling of legislation that had previously supported farming families and that undermined decades of hard work and investment in return for a ‘quick profit’. Drawing on notions of mutual obligation and distributive justice, growers in the study perceived these transgressions and the ensuing lack of ‘care’ shown to them to be a clear breach of social, corporate and ethical responsibility (Bryant and Garnham, 2013, 2014). In this context, efforts to impose responsibility on farmers to recognize risk factors and to make sound choices with regards to their mental health and well-being constitute a form of abandonment by government (Bryant and Garnham, 2014). This is further complicated by the dominant market-based logic that shapes mental health service system responses to suicide, and in which psychiatric and pharmacological interventions and treatments are claimed to provide the most effective solutions—claims that benefit the economic and political order simultaneously (Summerfield, 2012; Mills, 2014). This masking of the structural causes of suicide in public and professional discourse conceals and suppresses important analyses of the connection between policies that increase social inequalities and suicide, and those that profess to proffer solutions to the problem (Mills, 2014). This rearticulation of localized expressions of injustice and social inequality into psychic suffering is not isolated to farmer suicides, but is perceptible in the discourses that circulate around other marginalized and vulnerable groups that are more likely to die by suicide such as Indigenous people, the unemployed, those from sexually diverse populations and those in the criminal justice system. Rather than viewing farmer suicide as inherently political, a case can be made for considering suicides within these groups as similarly shaped by social inequalities and economic and political reform, albeit in markedly different contexts (Mills, 2014). Initiatives to Increase Action on the Social Determinants of Mental Health and Suicide The need to enlarge our current ways of talking about suicide to find productive ways to discuss the harms caused by structural processes and the obligations of the state and other organizations to address them is clearly important. The concept of ‘structural violence’ is useful here, as it provides a means for articulating the often pernicious structural processes that impact upon human lives and that are so complex, multilayered and diffuse as to make ascriptions of responsibility difficult (Ferguson, 2012). Because the concept of structural violence emphasizes the systematic inequalities that impact mental health, it offers an opportunity to change the prevailing moral and political discourse of suicide prevention to focus on important issues of rights and justice. But how, in such cases, do we move beyond the mere allocation of positive responsibility to the state to effecting policies that right existing inequalities and lessen subsequent ones in an effort to reduce the incidence of suicide. The necessity of including the whole of government in efforts to prevent suicide has long been acknowledged. In the Australian policy context, there is a gap between talk and action in the area of the social determinants of suicide. This may be attributed to the fact that government responsibility for suicide prevention rests mainly with the provision of primary care, hospital and community-based services, and through funding of non-governmental organizations involved in promotion and prevention activities, while the main determinants of suicide exist outside the health sector. Health-supporting public policies that address many of the determinants of suicide such as education, housing, vocational training and employment indicate an aspiration on the part of governments to achieve integrated solutions across sectors (New South Wales Department of Health, 2010). However, recognizing the importance of policies and programs that address the social determinants of suicide is not the same as recognizing the systematic factors that determine their distribution. Risk factors for suicide are heavily associated with systematic patterns of disadvantage in social, economic and political life. Addressing these factors, therefore, requires the development of new theoretical, practical and political approaches that consider the values, assumptions and goals that produce these inequalities, and the systematic response among all levels of government needed to address them (Gostin and Powers, 2006; Harris and Harris-Roxas, 2010). The model of government coordination required is thus more sophisticated than that currently set out in suicide prevention frameworks and policies and requires the involvement of all relevant government sectors in considering how public policy directly impacts upon mental health and suicide (Carey et al., 2014). The feasibility of a whole of government initiative that implicates multiple government departments at federal, state and local levels raises critical questions about leadership, accountability, as well as organizational structure, objectives and culture (Christensen and Lægreid, 2007). This is especially relevant given the shift to regionally delivered mental health and suicide prevention services within the Australian National Suicide Prevention Strategy and the increased fragmentation of the sector. At the same time, an inability to curb rates of suicide despite increases in funding and research over previous decades means there is increasing pressure on governments to show political leadership for suicide prevention, and to coordinate policy development and implementation. A number of strategies have been proposed as a way of enhancing whole of government systems and addressing the social determinants of health at a government level. One well-established practical mechanism with an explicit health focus is Health Impact Assessment (HIA). Originally developed in response to concerns about the impact of the physical environment on health, HIAs have become increasingly part of legislative and regulatory requirements aimed at minimizing the potential health impacts of major project developments in transport, housing and community development (Harris-Roxas and Harris, 2011; Harris and Spickett, 2011). More recently, the field of public health has identified HIA as an important mechanism to assess the potential health consequences of policies and programs from non-health sectors in line with a social view of health. Despite increasing use of HIAs, there is considerable diversity in practice, and evidence of effectiveness depends on the salience of different factors for HIA participants (Haigh et al., 2013). Different forms of HIA, for example, draw on different conceptualizations of health, employ different epistemological and methodological perspectives and serve markedly different purposes (Harris-Roxas and Harris, 2011). Three of these with particular relevance for this work are decision-support HIAs, advocacy HIAs and community-led HIAs. Drawing on the work of Elizabeth Harris and Ben Harris-Roxas (2010, 2011), I will provide a brief overview of these models and discuss their relevance for including the whole of government and whole of community in efforts to improve the social determinants of poor mental health, distress and suicide. Decision-support HIAs seek to improve decision-making and implementation of policies to minimize negative health impacts and maximize positive health impacts. They are normally conducted by, or with the agreement of, the agency responsible for the policy, and findings are intended to inform the policy development cycle. Ideally, decision-support HIAs should be undertaken before a policy has been developed to enable analysis of policy planning activity earlier in the cycle. But given the lack of clarity about the role for government and their capacity to undertake decision-support HIAs, this is often not the case. The development of the ‘health lens’—a key component of the Health in All Policies model used by the South Australian Government—represents an emergent methodology for translating the HIA process into action that emphasizes the importance of sustained and meaningful stakeholder involvement in identifying and assessing policy alternatives. In contrast to decision-support HIAs, advocacy HIAs are undertaken by groups or organizations that are not directly involved in the decision-making process, but that seek to influence the design and implementation of policies. In particular, advocacy HIAs seek to broaden the scope of the policymaking process in order for unexamined health consequences to be addressed, especially in those cases where the views of those most likely to be impacted by a specific policy are under-represented. Advocacy HIAs are thus an important tool for addressing the potential health inequities of a policy across populations, and involve a clear articulation of values in relation to both ethics and evidence. A more explicit role for values and value judgments can also be found in community-led HIAs where the community directly undertakes the HIA process—usually in response to the implementation of a specific policy—and where community values play an important role in evaluating evidence and impacts. Values are a critical force in suicide prevention advocacy; not just in mobilizing public support, but in making judgements about evidence and clarifying a scope of action (Carter et al., 2011; Alkire and Chen, 2004). Advocates of suicide prevention, however, rarely draw on ethical systems of reasoning to justify why a particular action should proceed. Discussions on whether to frame suicide prevention in terms of equitable access to mental health care, fair treatment of the disadvantaged or the best possible outcome for the greatest number of people can influence suicide prevention in important ways. An example is the implication of improving access to mental health services versus social justice and rights-based approaches that encourage the design of more culturally appropriate and practically oriented crisis services. In the former, suicide prevention invests heavily in mental health literacy, telehealth and online treatment to attract people into mental health services. This sounds worthwhile until one recognizes that many individuals prefer to manage their suicidal crisis outside of health care settings due to ineffective treatment, dissatisfaction with mainstream services or previous contact with uncaring practitioners (Pitman and Osborn, 2011). On the contrary, social justice and rights-based approaches would encourage active participation of service users in the co-design of services so that they meet the needs of people who are suicidal. Values clarification of the kind encouraged by HIAs has the potential to enable greater transparency of suicide prevention practice in the domains of ethics and evidence, as well as encouraging more deliberate exposition of ethical concepts including respect and participation (Carter et al., 2011). The important role of advocacy and community-led HIAs in identifying and articulating societal norms and values can also result in significant social learning as community groups and organizations develop a more nuanced understanding of a problem and the competing systems of ethical reasoning that underpin alternative positions. The emphasis on dialogue and increased interaction between stakeholders with divergent opinions that are a feature of social learning and the HIA process may also enhance practices of reason-giving, political accountability and deliberative democracy (Alkire and Chen, 2004; Harris-Roxas and Harris, 2011). Beyond clarifying why an action is important, HIAs can open a space for discussion of important social and common goods that fall outside the realm of liberal medical ethics (Dawson, 2011). Awareness of such goods is critical to identifying the values and goals of society that hinder their realization and that drive the distribution of the social determinants of suicide (Harris and Harris-Roxas, 2010). They also provide important normative justification for collective action. If suicide prevention advocates are to affect the kind of political and collective action needed to address the complex problem of suicide, then an explicit concern with ethical concepts such as equity, social justice, mutuality, fairness, democracy, self-determination, community and responsibility is required. Efforts to highlight the importance of the social determinants of mental health and suicide through the provision of evidence and policy options are invariably met by resistance from political forces opposed to such an agenda (Raphael et al., 2008). This has been exemplified in recent disputes over the impact of austerity measures on increased suicide rates in several European countries (Stuckler and Basu, 2013). If reforms aimed at establishing a whole-of-society approach to suicide prevention are to be more than rhetorical in their claims, a fundamental shift in moral and political discourse is required so that different forms of ethical and political recognition and responsibility are acknowledged by suicide prevention researchers, policymakers and practitioners (see, for example, Ferguson, 2012). To this end, researchers and practitioners must seek to build research and services around the social and political determinants of suicide. Lower-level politics, including grassroots advocacy and cooperative action between local governments and community organizations and groups, is also critical for improving whole-of-government initiatives that cannot always be imposed from the top down (Christensen and Lægreid, 2007). Indeed, given the siloed nature of government structure and practice, social determinants advocacy may be more effective focusing on smaller interventions and for distinct populations (Crammond and Carey, 2017). Improvements to public policy will also require supportive government infrastructure to build HIA capacity and extend its reach to redress current social and political inequalities that are the drivers of suicide, especially among disadvantaged groups (Harris and Spickett, 2011; Carey et al., 2014). Conclusion In this work I have sought to broaden existing ethical debate on suicide by examining key moral dimensions of current suicide prevention policy and practice and their potentially wider implications. Because normative justification for current preventive practice is conceptually and theoretically underdeveloped, and is dependent upon implicit value judgements in research and political decision-making, the reasoning underpinning national and local suicide prevention strategies is problematic and reproduces a number of systematic inequalities that undermine public mental health and well-being, especially among disadvantaged groups and communities. The focus on suicide as a primarily individual and clinical problem that informs these strategies manifests itself pronouncedly in uneven and conflicting relations of responsibility for suicide prevention that pose a number of potential harms and burdens, as well as further barriers to prevention. The need to address sensitive social, political and ethical concerns such as decisions about resources, the impact of structural factors on suicide, the translation of research into policy and practice, and the nature of responsibility for suicide prevention points to the importance of ethical thinking through a public health ethics framework in relation to suicide prevention. Successfully achieving transformative change in suicide prevention requires that public and mental health advocates, community groups and organizations develop practicable and ethical forms of critique that take seriously concepts of equity, social justice, vulnerability and social responsibility in an effort to capture the attention of policymakers and to force action on the social determinants of suicide. Acknowledgements I would like to acknowledge the assistance of Christopher Mayes who provided helpful comments on a first draft of this manuscript. References Alkire S. , Chen L. ( 2004 ). 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Reshaping the Ethics of Suicide Prevention: Responsibility, Inequality and Action on the Social Determinants of Suicide

Fitzpatrick, Scott J
Public Health Ethics , Volume Advance Article (2) – Nov 21, 2017
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Oxford University Press
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© The Author 2017. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
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Abstract

Abstract Value judgements in research and political decision-making that exclude evidence for the social determinants of suicide suggest that evidence is not sufficient on its own to guide policy and practice, and that there is a lack of conceptual clarity with regard to decisions relating to the prioritization of problems, the allocation of resources, the translation of research into practice, as well as questions of responsibility for suicide prevention. In this work I seek to broaden conventional ethical debate about suicide through the use of public health ethics frameworks. I argue that despite espousing a public health approach, current suicide prevention strategies are based largely on individual-level theorizing. This emphasis on the individual works to responsibilize individuals and communities for suicide prevention and directs attention away from public policy and systemic inequities. Given continued high rates of suicide, especially among disadvantaged social groups and communities, comprehensive government action is required to address the social and political determinants of suicide. Normative justification for action in realizing these ends is critical. I conclude by proposing one practicable form of action to make values and value judgements in suicide prevention explicit so that alternative forms of ethical and political recognition and responsibility are acknowledged. Introduction For most of the 20th and well into the 21st century ethical discussion of suicide in the West has been largely confined to the margins of suicidology (Cardinal, 2008; Battin, 2015). Broadly conceived as the science of suicide and suicide prevention, suicidology has become a powerful social practice delineated by specific normative, epistemological and methodological commitments that privilege biomedicine (Fitzpatrick et al., 2015). Consequently, with few exceptions, most extant work on the ethics of suicide is based on an individualistic conceptualization of suicide. This individualistic orientation is consonant with the dominant intellectual and political culture of formalized suicide research and prevention, but also with predominant views in bioethics that have traditionally prioritized individual over population interests. A considerable body of work, for example, has directed attention toward the norms of care governing the management and treatment of suicidal patients and, in particular, the use of coercive, invasive or emergency interventions and their implications with regard to the rights, interests, values, dignity and capacity of persons who are suicidal (Sontheimer, 2008; David et al., 2010). Ethical issues associated with suicide research have also been the focus of some discussion (Stanley, 1986; Mishara and Weisstub, 2005; Lakeman and Fitzgerald, 2009). These works also draw heavily on concepts and language inherited from clinical ethics and research ethics including confidentiality, duty of care to research participants and disclosure of risk. Despite this focus on the individual and the framing of suicide as a major preventable mental health problem, it is widely accepted that a range of social, cultural and political factors contribute to suicide. Adverse economic conditions, insecurity of employment, trauma, abuse, discrimination, poverty, inequality, social isolation and exclusion are all factors that put persons at risk of suicide (World Health Organization, 2014). Subsequently, public health organizations, academics and advocates have long highlighted the need to acknowledge and address the social determinants of mental health and suicide (Stuckler and Basu, 2013; Mills, 2014). Yet, despite broad consensus on the importance of the social determinants of mental health and the provision of evidence-based recommendations to address them (Commission on Social Determinants of Health, 2008), suicide prevention frameworks responsive to this emerging knowledge are yet to be fully developed. Current population-based interventions that aim to increase access to mental health services through mental health literacy and community awareness programs, for example, continue to operate within an individualistic framework aimed at identifying psychological and behavioral risk factors. The understanding that suicide is strongly influenced by social and political determinants and that political action has increasing relevance to suicide prevention policy gives rise to a number of ethical issues outside the parameters of traditional bioethical approaches to suicide (Dawson and Silva, 2009). Because suicide raises concerted moral and political debate about the underlying causes of suicidal distress and the action that is needed to address this important issue, ethical reasoning is a critical political force in suicide prevention and has noticeable effects on the way suicide is constituted as an ‘issue’ and the political claims made by public institutions, professionals and user groups as justification for action. Narratives of suffering, trauma and misfortune draw our attention to the plight of farmers, youth, Indigenous and First Nation communities and other at-risk populations in an effort to compel policymakers to action. The bases for suicide prevention is therefore underpinned by a set of values for determining what is right and good, and how suicide prevention should be implemented to ensure that it reflects the needs and values of those that it is intended to serve. A central problem of suicide prevention policy and practice, however, is its conceptual vagueness regarding the ethical bases for decisions relating to, for example, the prioritization of problems, the allocation of resources, the translation of research into practice, as well as conceptualizations of risk and responsibility for suicide and its prevention. And while many local and national suicide prevention policies and strategies promote ethically relevant concepts such as social responsibility, empowerment, equality, vulnerability and care (Australian Government Department of Health and Ageing, 2000, 2007), they are rarely defined in any detail or with reference to existing ethical theory or empirical evidence. These concepts, moreover, are embedded in social and political contexts in which relations between the state and its citizens regarding risk and responsibility for suicide are constantly being redrawn. The above concerns point to the importance of broadening the traditional focus of ethical approaches to suicide to include discussion of suicide and its prevention as a public health issue. Given this is a largely unexamined area in the contemporary context, this work does not aim to provide a comprehensive ethical analysis of the many and varied activities that currently make up suicide prevention practice, but rather to direct attention to a number of its salient features to stimulate ethical reflection and to expand the current parameters of ethical debate. To begin, I establish suicide as a public health issue and discuss the advantages of public health ethics approaches for examining the distinct moral features of suicide prevention at a social and political level. Following this, I describe current approaches to suicide prevention that increasingly emphasize the need for intersectoral collaboration and multilevel approaches. Although the documents that are the focus of analysis in this work derive primarily from the Australian context, they reflect current trends in international suicide prevention practice in relation to evidence and the eschewal of the socioeconomic determinants of suicide. This strong bias toward understanding suicide as individual rather than societal, I argue, has led to the fostering of unjust relations of responsibility for suicide prevention that create a number of potential burdens and harms for individuals and communities, and I use the example of farmer suicide to illustrate this. In closing, I make a case for the use of specific policy and advocacy tools as a way of redressing existing inequalities and enhancing whole of government systems to address the social and political determinants of suicide. Suicide as a Public Health Issue and the Role of Public Health Ethics Recent work in public health ethics has identified the shortcomings of dominant individualist ethics frameworks for examining public health (Jennings, 2007; Baylis et al., 2008; Dawson, 2011). What these works hold in common is the view that health is significantly different when considered from a public health as opposed to a clinical or individual perspective, and that clear articulation of the aims and methods of public health is required prior to analysis of public health ethics issues (Jennings, 2007; Dawson, 2011). There are three central issues I would like to briefly touch upon in establishing suicide as a public health issue. First, because public health is primarily focused on the health of the population or community and not just with the health of individuals (Dawson, 2011), it takes into account the ways in which membership in particular social groups shapes the ways that persons are socially, politically and economically situated with regards to systematic privilege or disadvantage, how these impact upon health status and accordingly, the goals and activities of public health (Baylis et al., 2008). Writing on the role of public health and public health ethics in suicide prevention, Dawson and Silva (2009) contend that because many of the causes of suicide extend beyond individual behavior to the population level (for example, injustice, discrimination, mental illness) and relate to membership of various social groups and communities (for example, Indigenous; Lesbian, Gay, Bisexual, Transgender, Intersex, Queer; those in the criminal justice system) they can also be addressed through population-based preventive strategies. Second, public health activity is directed toward preventing and reducing harm at a population level and not just providing treatment (Dawson, 2011). This concern with the health of the population or community is evident in such preventive activity as the responsible media reporting of suicide; means restriction; and school-based and community peer-support, education and awareness programs, as well as those targeting groups at high risk in the community. Such interventions derive from inferences made regarding population risks and that programs will reach these individuals and result in fewer suicides. Third, because the contexts in which people live their lives may limit or expand the opportunities for them to be healthy and to make decisions about their health, the attainment of many public health goals is beyond the individual and requires collective action (Jennings, 2007; Baylis et al., 2008; Dawson, 2011). Because such interventions usually require action at a social and political level, moral justification for them can be especially demanding (Jennings, 2007). Consideration of the nature, aims and methods of public health practice in the field of public health ethics has led to increasing concern over the inadequacy of prevailing liberal medical ethics frameworks for thinking about public health ethics issues. The focus on individual autonomy, rights and interests that underpin these approaches are considered insufficient for the ethics of public health where concerns with collective interests are of greater importance (Jennings, 2007; Kenny et al., 2010). One of the primary tasks of recent work in public health ethics, therefore, has been the cultivating of more suitable conceptual and analytic frameworks able to capture the distinctive moral features of public health practice and public well-being, and to assess the systematic inequalities that undermine public health to guide action at the social and political levels to address them (Rogers, 2006; Kenny et al., 2010). Current ‘Best Practice’ in Suicide Prevention Suicide prevention in Australia and other high-income countries draws on international evidence that supports the use of multicomponent interventions. While differences exist with regards to the number and choice of core components that comprise local and national suicide prevention strategies, a number of best practice activities have evolved to guide policymakers and practitioners in their development (World Health Organization, 2014). Evidence for multicomponent interventions is positive, with their implementation associated with short-term decreases in suicide and suicidal behavior in several European trial regions (Székely et al., 2013). Despite existing evaluations showing limited efficacy for several individual system components such as community awareness, gatekeeper training and school-based prevention programs (Mann et al., 2005; Scott and Guo, 2012; Caine, 2013), proponents argue that it is the strong synergistic effects of these multi-tiered strategies that account for their overall effectiveness (van der Feltz-Cornelis et al., 2011; Székely et al., 2013). Some caution should be exercised when assessing these claims, however, particularly given that research has been unable to identify which of the individual system components might be most relevant, and that there has been no research examining the important role of other mediating factors—including culture—on outcomes, or assessment of the long term-term influence of these interventions on suicide rates. As they are currently conceived, multicomponent approaches focus almost exclusively on intersectoral collaboration and the coordination and integration of mostly existing intervention strategies as opposed to considering the deeper system structures that exert strong influence on suicide prevention practice such as research and the policymaking process. Discussion of the social and structural determinants of suicide and preventive strategies that focus on addressing broader political, economic and social issues also remain outside the system boundary. In its recent report, Preventing Suicide: A Global Imperative (WHO, 2014), the World Health Organization made no mention of the importance of addressing social determinants in its list of typical components for the creation of comprehensive national suicide prevention strategies. This is exemplified in current ‘systems’ approaches in Australia that deliberately eschew the social determinants of suicide in favor of short-term actions aimed at having a swift positive impact on reducing suicide rates in accordance with national and global targets (NHMRC Centre for Research Excellence in Suicide Prevention and Black Dog Institute, 2015). Given these assessments, it would be reasonable to expect that the deliberate exclusion of the social determinants of suicide within multicomponent approaches reflects a general lack of evidence with regard to their significance. Yet the longstanding and pervasive body of evidence that shows a relationship between suicide and socioeconomic factors, and the emerging body of evidence from Europe that has shown the benefits of non-health sector policy on reducing unemployment-related suicide does not support this position (Taylor et al., 2005; Milner et al., 2012; Stuckler and Basu, 2013). While the coordination of activities is important given the siloed nature of suicide prevention, the primary challenge for suicide prevention moving forward is not solely a lack of evidence for what works as is often presumed, but from a set of value judgements about research evidence and political decision-making that hinder action on the social determinants of suicide. The narrow ‘evidence-based’ framing of policymaking has been shown to be inconsistent with the way it actually occurs (Black, 2001; Greenhalgh and Russell, 2009). In the case of transformative policy change, the presence of research evidence alone may not be sufficient justification for change, especially when the proposed changes challenge the set of widely held philosophical beliefs about the role of government in matters relating to broader mental health determinants such as racism, poverty and violence (Gostin and Powers, 2006; Crammond and Carey, 2017). In such cases, ethical, rather than evidence-based, arguments may be of significantly greater importance to the successful realization of policy change (Crammond and Carey, 2017). The multidimensional character of suicide ‘risk’ leads us to question the system of shared responsibility for suicide prevention and the ethical implications of seeking to prevent suicide without addressing the root causes of poor mental health, distress and suicide (Dawson and Silva, 2009). Essential treatment of mental health problems should not, after all, be conflated with suicide prevention as a public health concern (Caine, 2013). Following this, we might ask what harms occur if public health research findings are not translated into suicide prevention policy and no benefits accrue from this research (Kass, 2001). These arguments raise a set of challenging questions about how different forms of responsibility for suicide prevention are envisioned and enacted within current policy and practice. In the remainder of this article, I outline the assumptions and principles of responsibilization that underpin contemporary suicide prevention policy and practice, and in doing so, make an argument for why those working to prevent suicide should be concerned about the harms caused by the failure to act on the social determinants of suicide, and the kinds of political and collective action needed to address them. Configuring Relations of Responsibility for Suicide Prevention Responsibility for suicide prevention extends across multiple domains. These include the suicidal or previously suicidal person’s responsibility to him or herself and to others to minimize risk by seeking help and complying with treatment recommendations. Other forms of responsibility are evident in policy documents and interventions directed toward families, communities, schools, sporting clubs, workplaces, media and health and community professionals and organizations. These broadly stipulate the importance of community ownership and responsibility in preventing suicide, although in practice what this means is unclear. In most cases it is used to establish the foundation for embedding suicide prevention activities, namely, education, gatekeeper training programs and responsible media representations within the whole of community. Responsibility is also attributed to mental health professionals and institutions that have a significant duty in caring for persons who are suicidal. Another form of responsibility is that which has been taken up by organizations engaged in suicide and mental health education and promotion. Responsibility for suicide prevention is also assumed by federal, state and local governments who oversee funding commitments, outcomes and specific policy directions (Australian Government Department of Health and Ageing, 2007). These relations of responsibility are characterized by different reciprocities of trust, care, accountability and obligation and, therefore, require closer analysis of what competing responsibilities entail (Trnka and Trundle, 2014). Notions of building individual and community strength, resilience and capacity—so often evident in suicide prevention policy—illustrate how ideals of responsibility are enmeshed within the logics of neoliberalism and the set of broader, complex political and economic practices shaping contemporary social relations (Shamir, 2008; Trnka and Trundle, 2014): Resilience is the ability to bounce back after experiencing trauma or stress, to adapt to changing circumstances and respond positively to difficult situations. It is the ability to learn and grow through the positive and the negative experiences of life, turning potentially traumatic experiences into constructive ones. Being resilient involves engaging with friends and family for support, and using coping strategies and problem-solving skills effectively to work through difficulties (Australian Government Department of Health and Ageing, 2007). While not discounting the need for resilience approaches, we should be cautious of their position of dominance in the suicide prevention field (Harper and Speed, 2012). Processes of individualization and responsibilization have been widely linked to neoliberal ideals including the decline in government spending on the collective health and well-being of citizens, and a strong bias toward understanding principal mental health challenges as individual rather than societal (Raphael et al., 2008; Teghtsoonian, 2009). Therefore, while the obligation of mental health services to provide appropriate and continuing care for suicidal individuals or those at risk presupposes a duty of care to the welfare of others, this commitment to care exists in dialogical relationship with neoliberal ideals of personal and interpersonal responsibility and accountability that directs attention away from public policies and systemic inequities (Teghtsoonian, 2009; Trnka and Trundle, 2014). The discursive strategies visible in suicide prevention communication campaigns that presume suicide to be driven by individual pathology, and that in turn work to responsibilize individuals, families, workplaces and communities for suicide prevention, pose a number of potential burdens and harms. Over the past decade, various studies have examined the self-management techniques performed by individuals to reduce harm and risk and to preserve their mental health, and how these enactments are aligned with neoliberal policy orientations and, in particular, the framing of mental ill health and distress as originating in individual bodies and minds (Teghtsoonian, 2009; Trnka and Trundle, 2014). In the case of attempted suicide, enactment of the responsibilized individual is further entangled in complex dynamics around moral responsibility where the assuaging of individual blame and censure is bound inextricably with practices of accountability that construct one as responsive, prudent and resourceful in managing further conduct. Here, the interrelationship between mental health and suicide literacy, and the provision of appropriate and continuing clinical care for suicidal persons or those at risk, are presented as two sides of the same coin. In this view, the provision of information to individuals and collectives (families, workplaces and so forth) can enhance individual knowledge and skills, helping people to make better decisions regarding their own and others mental and emotional well-being and the types of services and supports required to assist them (Teghtsoonian, 2009). This sleight of hand works not only to transfer responsibility to individuals and collectives, suggesting that risk is somehow under individual control, it explains people’s avoidance of clinical services as a result of ‘poor mental health literacy’, ‘negative beliefs’ and ‘stigma’ rather than dissatisfaction with, or the inappropriateness of, existing services (Taylor et al., 2009; Mills, 2014). This ethic of self-care is manifested in various self-management practices such as disclosing and controlling negative emotions and reframing understandings of suicide and distress—practices that have been shown to pose additional individual and social burdens (Brownlie, 2012; Fitzpatrick, 2014). Families, workplaces and communities are important sites of support, and mental health education and training programs make the assessment of other’s thoughts, emotions and actions a key task in helping them to identify and reduce risk. Such programs have focused on positioning emotional disclosure as beneficial, and consequently, eliciting and hearing personal stories of emotional or psychological distress is encouraged. Yet such approaches may impose undue burdens on particular segments of society through the obligating of peers to promote access to care, and the burden of dealing with challenging issues such as substance use, interpersonal violence, sexual identity and family disintegration (Kalafat, 2003). The kinds of surveillance and assessment techniques necessitated by these approaches may also undermine conditions of trust and reciprocity between persons. The emphasis on assessment and referral can appear paternalistic through its prioritizing of risk containment over personal relationships, especially when supportive relationships based on unconditional acceptance, understanding and empathy may be of far greater importance (Brownlie, 2012). Practices of care are enacted through intimate face-to-face relationships and between collectivities, and the above practices do not necessarily preclude the provision of compassionate care (Trnka and Trundle, 2014). My focus here is not on specific care practices per se, but rather, how certain kinds of responsibility are nourished and legitimated via these practices and in dialogical relationship with liberal democratic values, goals and orientations. The view of responsibility that underpins such approaches is of people acting in a way that presupposes the needs and interests of others. Moreover, in operating primarily through a moral language of suffering and compassion, other forms of expression and social relations are masked, with perceptible effects for public and private practices (Fassin, 2012). The move to contextualize practices of responsibility to show how individuals and communities are nested within multiple relations of dependency, reciprocity and obligation shifts attention to the moral and political values upon which particular kinds of responsibility are founded and legitimated (Trnka and Trundle, 2014). A good example of this, and how uneven and conflicting relations of responsibility can impose additional harms and burdens on individuals and communities, is the issue of farmer suicide. Uneven and Conflicting Relations of Responsibility in Farmer Suicide As with other health and social problems that are shaped by economic, political and environmental factors, responsibility cuts across multiple domains (Trnka and Trundle, 2014). One example of intersecting responsibilities is the issue of farmer suicide. In India, farmer suicide has become increasingly politicized with high rates of suicide in some regions coming to symbolize, to a greater or lesser extent, a precarious agrarian existence in the context of industrial modernization, neoliberal reform and the failure of the nation state to protect its agrarian population (Münster, 2012). Because farmer suicides are not self-evident types of death but become reified through discourse and the classificatory practices of the state, the politicized nature of suicide in India has had a significant impact on policy and program design, as well as providing farmers with a frame for comprehending their distress and the effects of large-scale economic and political processes on their lives (Münster, 2012). While this has inspired farmers to activism and collective action, and led to the introduction of general programs aimed at ameliorating debt and generating employment for rural workers, the extent and justification for state and corporate responsibility are contested. Recognition of the socio-political and economic determinants of suicide does not necessarily translate into structural change at the state level. Indeed, even in those contexts where economic and political factors are acknowledged, interventions often remain focused on individual-level factors due to the incapacity of services to engage with these larger problems on the ground, the subsequent reframing of polyphonic presentations of distress through a dominant psychiatric nosology, as well as conflicting views on the role of government (Mills, 2014; Crammond and Carey, 2017). In Australia, environmental and political issues affecting farmers’ health and well-being such as drought, agricultural subsidies, animal welfare and land and water use and management have also been problematized through a mental health lens. The solutions put forward, again, operate primarily at the individual level. For example, one of the main areas of action put forward by the NSW Farmers Mental Health Blueprint is to enhance the resilience of individuals and families to manage the pressures of life and work on the farm (Australian Centre for Agricultural Health and Safety, 2016). These attempts to responsibilize farming communities are evident in discourses and practices that not only encourage individuals to access appropriate welfare and social support, but that emphasize the importance of management skills development. In this view, farmers are urged to calculate the potential impacts of business pressures on their health and well-being and to consider other options such as capital investment, more efficient practices or to ‘just walk off the land’ (Scarr and Anthony, 2011; Bryant and Garnham, 2014). In certain contexts, such moves toward responsibilization are considered unjust. A recent study of Australian wine grape growers, for example, highlighted the perceived injustices experienced by growers as a result of state and corporate intervention in the wine industry (Bryant and Garnham, 2013, 2014). Such perceptions of injustice were the potential basis for distress, but also for expressions of moral outrage at the violation of loyalty, trust and respect in social and economic relations between grape growers, wineries and the state. The connection between farmer distress and emotions such as anger and contempt exemplifies cognitive and cultural conceptualizations of emotion in which beliefs and moral judgements have a central role (Harré, 1986). Emotions of shame and guilt were common to farmers’ experiences of distress and closely bound with perceptions of self-worth and attributions of personal responsibility. However, farmers also apportioned blame for their troubles to the government’s dismantling of legislation that had previously supported farming families and that undermined decades of hard work and investment in return for a ‘quick profit’. Drawing on notions of mutual obligation and distributive justice, growers in the study perceived these transgressions and the ensuing lack of ‘care’ shown to them to be a clear breach of social, corporate and ethical responsibility (Bryant and Garnham, 2013, 2014). In this context, efforts to impose responsibility on farmers to recognize risk factors and to make sound choices with regards to their mental health and well-being constitute a form of abandonment by government (Bryant and Garnham, 2014). This is further complicated by the dominant market-based logic that shapes mental health service system responses to suicide, and in which psychiatric and pharmacological interventions and treatments are claimed to provide the most effective solutions—claims that benefit the economic and political order simultaneously (Summerfield, 2012; Mills, 2014). This masking of the structural causes of suicide in public and professional discourse conceals and suppresses important analyses of the connection between policies that increase social inequalities and suicide, and those that profess to proffer solutions to the problem (Mills, 2014). This rearticulation of localized expressions of injustice and social inequality into psychic suffering is not isolated to farmer suicides, but is perceptible in the discourses that circulate around other marginalized and vulnerable groups that are more likely to die by suicide such as Indigenous people, the unemployed, those from sexually diverse populations and those in the criminal justice system. Rather than viewing farmer suicide as inherently political, a case can be made for considering suicides within these groups as similarly shaped by social inequalities and economic and political reform, albeit in markedly different contexts (Mills, 2014). Initiatives to Increase Action on the Social Determinants of Mental Health and Suicide The need to enlarge our current ways of talking about suicide to find productive ways to discuss the harms caused by structural processes and the obligations of the state and other organizations to address them is clearly important. The concept of ‘structural violence’ is useful here, as it provides a means for articulating the often pernicious structural processes that impact upon human lives and that are so complex, multilayered and diffuse as to make ascriptions of responsibility difficult (Ferguson, 2012). Because the concept of structural violence emphasizes the systematic inequalities that impact mental health, it offers an opportunity to change the prevailing moral and political discourse of suicide prevention to focus on important issues of rights and justice. But how, in such cases, do we move beyond the mere allocation of positive responsibility to the state to effecting policies that right existing inequalities and lessen subsequent ones in an effort to reduce the incidence of suicide. The necessity of including the whole of government in efforts to prevent suicide has long been acknowledged. In the Australian policy context, there is a gap between talk and action in the area of the social determinants of suicide. This may be attributed to the fact that government responsibility for suicide prevention rests mainly with the provision of primary care, hospital and community-based services, and through funding of non-governmental organizations involved in promotion and prevention activities, while the main determinants of suicide exist outside the health sector. Health-supporting public policies that address many of the determinants of suicide such as education, housing, vocational training and employment indicate an aspiration on the part of governments to achieve integrated solutions across sectors (New South Wales Department of Health, 2010). However, recognizing the importance of policies and programs that address the social determinants of suicide is not the same as recognizing the systematic factors that determine their distribution. Risk factors for suicide are heavily associated with systematic patterns of disadvantage in social, economic and political life. Addressing these factors, therefore, requires the development of new theoretical, practical and political approaches that consider the values, assumptions and goals that produce these inequalities, and the systematic response among all levels of government needed to address them (Gostin and Powers, 2006; Harris and Harris-Roxas, 2010). The model of government coordination required is thus more sophisticated than that currently set out in suicide prevention frameworks and policies and requires the involvement of all relevant government sectors in considering how public policy directly impacts upon mental health and suicide (Carey et al., 2014). The feasibility of a whole of government initiative that implicates multiple government departments at federal, state and local levels raises critical questions about leadership, accountability, as well as organizational structure, objectives and culture (Christensen and Lægreid, 2007). This is especially relevant given the shift to regionally delivered mental health and suicide prevention services within the Australian National Suicide Prevention Strategy and the increased fragmentation of the sector. At the same time, an inability to curb rates of suicide despite increases in funding and research over previous decades means there is increasing pressure on governments to show political leadership for suicide prevention, and to coordinate policy development and implementation. A number of strategies have been proposed as a way of enhancing whole of government systems and addressing the social determinants of health at a government level. One well-established practical mechanism with an explicit health focus is Health Impact Assessment (HIA). Originally developed in response to concerns about the impact of the physical environment on health, HIAs have become increasingly part of legislative and regulatory requirements aimed at minimizing the potential health impacts of major project developments in transport, housing and community development (Harris-Roxas and Harris, 2011; Harris and Spickett, 2011). More recently, the field of public health has identified HIA as an important mechanism to assess the potential health consequences of policies and programs from non-health sectors in line with a social view of health. Despite increasing use of HIAs, there is considerable diversity in practice, and evidence of effectiveness depends on the salience of different factors for HIA participants (Haigh et al., 2013). Different forms of HIA, for example, draw on different conceptualizations of health, employ different epistemological and methodological perspectives and serve markedly different purposes (Harris-Roxas and Harris, 2011). Three of these with particular relevance for this work are decision-support HIAs, advocacy HIAs and community-led HIAs. Drawing on the work of Elizabeth Harris and Ben Harris-Roxas (2010, 2011), I will provide a brief overview of these models and discuss their relevance for including the whole of government and whole of community in efforts to improve the social determinants of poor mental health, distress and suicide. Decision-support HIAs seek to improve decision-making and implementation of policies to minimize negative health impacts and maximize positive health impacts. They are normally conducted by, or with the agreement of, the agency responsible for the policy, and findings are intended to inform the policy development cycle. Ideally, decision-support HIAs should be undertaken before a policy has been developed to enable analysis of policy planning activity earlier in the cycle. But given the lack of clarity about the role for government and their capacity to undertake decision-support HIAs, this is often not the case. The development of the ‘health lens’—a key component of the Health in All Policies model used by the South Australian Government—represents an emergent methodology for translating the HIA process into action that emphasizes the importance of sustained and meaningful stakeholder involvement in identifying and assessing policy alternatives. In contrast to decision-support HIAs, advocacy HIAs are undertaken by groups or organizations that are not directly involved in the decision-making process, but that seek to influence the design and implementation of policies. In particular, advocacy HIAs seek to broaden the scope of the policymaking process in order for unexamined health consequences to be addressed, especially in those cases where the views of those most likely to be impacted by a specific policy are under-represented. Advocacy HIAs are thus an important tool for addressing the potential health inequities of a policy across populations, and involve a clear articulation of values in relation to both ethics and evidence. A more explicit role for values and value judgments can also be found in community-led HIAs where the community directly undertakes the HIA process—usually in response to the implementation of a specific policy—and where community values play an important role in evaluating evidence and impacts. Values are a critical force in suicide prevention advocacy; not just in mobilizing public support, but in making judgements about evidence and clarifying a scope of action (Carter et al., 2011; Alkire and Chen, 2004). Advocates of suicide prevention, however, rarely draw on ethical systems of reasoning to justify why a particular action should proceed. Discussions on whether to frame suicide prevention in terms of equitable access to mental health care, fair treatment of the disadvantaged or the best possible outcome for the greatest number of people can influence suicide prevention in important ways. An example is the implication of improving access to mental health services versus social justice and rights-based approaches that encourage the design of more culturally appropriate and practically oriented crisis services. In the former, suicide prevention invests heavily in mental health literacy, telehealth and online treatment to attract people into mental health services. This sounds worthwhile until one recognizes that many individuals prefer to manage their suicidal crisis outside of health care settings due to ineffective treatment, dissatisfaction with mainstream services or previous contact with uncaring practitioners (Pitman and Osborn, 2011). On the contrary, social justice and rights-based approaches would encourage active participation of service users in the co-design of services so that they meet the needs of people who are suicidal. Values clarification of the kind encouraged by HIAs has the potential to enable greater transparency of suicide prevention practice in the domains of ethics and evidence, as well as encouraging more deliberate exposition of ethical concepts including respect and participation (Carter et al., 2011). The important role of advocacy and community-led HIAs in identifying and articulating societal norms and values can also result in significant social learning as community groups and organizations develop a more nuanced understanding of a problem and the competing systems of ethical reasoning that underpin alternative positions. The emphasis on dialogue and increased interaction between stakeholders with divergent opinions that are a feature of social learning and the HIA process may also enhance practices of reason-giving, political accountability and deliberative democracy (Alkire and Chen, 2004; Harris-Roxas and Harris, 2011). Beyond clarifying why an action is important, HIAs can open a space for discussion of important social and common goods that fall outside the realm of liberal medical ethics (Dawson, 2011). Awareness of such goods is critical to identifying the values and goals of society that hinder their realization and that drive the distribution of the social determinants of suicide (Harris and Harris-Roxas, 2010). They also provide important normative justification for collective action. If suicide prevention advocates are to affect the kind of political and collective action needed to address the complex problem of suicide, then an explicit concern with ethical concepts such as equity, social justice, mutuality, fairness, democracy, self-determination, community and responsibility is required. Efforts to highlight the importance of the social determinants of mental health and suicide through the provision of evidence and policy options are invariably met by resistance from political forces opposed to such an agenda (Raphael et al., 2008). This has been exemplified in recent disputes over the impact of austerity measures on increased suicide rates in several European countries (Stuckler and Basu, 2013). If reforms aimed at establishing a whole-of-society approach to suicide prevention are to be more than rhetorical in their claims, a fundamental shift in moral and political discourse is required so that different forms of ethical and political recognition and responsibility are acknowledged by suicide prevention researchers, policymakers and practitioners (see, for example, Ferguson, 2012). To this end, researchers and practitioners must seek to build research and services around the social and political determinants of suicide. Lower-level politics, including grassroots advocacy and cooperative action between local governments and community organizations and groups, is also critical for improving whole-of-government initiatives that cannot always be imposed from the top down (Christensen and Lægreid, 2007). Indeed, given the siloed nature of government structure and practice, social determinants advocacy may be more effective focusing on smaller interventions and for distinct populations (Crammond and Carey, 2017). Improvements to public policy will also require supportive government infrastructure to build HIA capacity and extend its reach to redress current social and political inequalities that are the drivers of suicide, especially among disadvantaged groups (Harris and Spickett, 2011; Carey et al., 2014). Conclusion In this work I have sought to broaden existing ethical debate on suicide by examining key moral dimensions of current suicide prevention policy and practice and their potentially wider implications. Because normative justification for current preventive practice is conceptually and theoretically underdeveloped, and is dependent upon implicit value judgements in research and political decision-making, the reasoning underpinning national and local suicide prevention strategies is problematic and reproduces a number of systematic inequalities that undermine public mental health and well-being, especially among disadvantaged groups and communities. The focus on suicide as a primarily individual and clinical problem that informs these strategies manifests itself pronouncedly in uneven and conflicting relations of responsibility for suicide prevention that pose a number of potential harms and burdens, as well as further barriers to prevention. The need to address sensitive social, political and ethical concerns such as decisions about resources, the impact of structural factors on suicide, the translation of research into policy and practice, and the nature of responsibility for suicide prevention points to the importance of ethical thinking through a public health ethics framework in relation to suicide prevention. Successfully achieving transformative change in suicide prevention requires that public and mental health advocates, community groups and organizations develop practicable and ethical forms of critique that take seriously concepts of equity, social justice, vulnerability and social responsibility in an effort to capture the attention of policymakers and to force action on the social determinants of suicide. Acknowledgements I would like to acknowledge the assistance of Christopher Mayes who provided helpful comments on a first draft of this manuscript. References Alkire S. , Chen L. ( 2004 ). 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Journal

Public Health Ethics – Oxford University Press

Published: Nov 21, 2017

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