Perspectives in biochemical sciences
Suicide: a Socratic revenge
Sachi Sri Kantha1

1Biochemist, Japan Institute for the Control of Ageing, 723-1 Haruoka, Fukuroi City 437-0126 Japan. (Accepted February 102000). This essay entered the shortlist of 6 for the Lancet's 1998 Wakely Prize Competition, but did not win.
Ceylon Medical Journal,
2000; 45: 25-28

Abstract
2400 years have passed since the occurrence in Ath­ens, Greece of one of the famous suicides recorded in hu­man history. This autobiographical essay provides a montage on the history of suicide, with snippets from the final hours of Socrates, as described by Plato. Suicide in con-temporary Japanese culture is also explored briefly, with reference to the deaths of internationally acclaimed movie directors Akira Kurosawa and Juzo Itami. The author also questions why no researcher has yet been honoured for the past 99 years with a Medicine Nobel prize for his or her work on suicidology or thanatology.

Suicide: a Socratic revenge
"Today is my birthday. I am so besieged by business people that I cannot get a moment to myself either at breakfast or at dinner Since Barbels death, everything has gone from bad to worse.... ft is all just becoming more and more complicated until one day I will probably decide to disappear without a trace, and without leaving a forwarding address..." (1)

[Alfred Nobel to Sofie Hess, letter dated October 21, 1890]

So wrote Nobel, following the suicide of his French business partner Paul Francois Barbe, an acquaintance of his for over 20 years. Barbe's death and the unfinished business affairs he left for Nobel, seem to have pulled Nobel down strongly into depression and melancholy to the extent that he wrote about "disappearing without a trace" - a sort of suicide note.

This year's Nobel prize for medicine has been an­nounced recently, and again the prize eluded researchers who have contributed to suicidology or thanatology. It seems ironic that for the past 99 years, not a single re­searcher was honoured for his or her work on suicide. But the Nobel honour roll also has its share of suicide victims; Bridgman - the physicist, Hemingway and Kawabata - the literati, and Emil Fischer and Hans Fischer - the chemists, are some names I remember.

Suicide has remained a puzzle for mankind since the dawn of civilisation. Over 2400 years ago Socrates made a political statement against his accusers, using the hem­lock extract (2). Plato, then a 28-year old protage of the master, has left for posterity a case history of the final moments of the Athenian iconoclast who rebelled against the dictates of the then Democrats. Plato's penetrating description of the 'original symposium' (though only his mentor provided a demonstration of how to imbibe hem­lock extract) still astounds me.

Socrates:     "You, my good friend, shall give me directions how I am top~~".

Prison attendant: "You have only to walk about until your legs are heavy, and then to lie down, and the poison will act".

Socrates     (with the cup of poison in his hapd): "What do you say about making a libation out of this cup to any God? May I, or not?

Prison attendant: "We only prepare, Socrates, just so much as we deem enough".

Socrates:     "I understand. Yet I may and must pray to the Gods to prosper my journey from this to that other world - may this then, which is my prayer, be granted to m&' (3).

Plato, in the words of Phaedo, has written that his mentor, "then holding the cup to his lips, quite readily and cheerfully he drank off the poison... and he walked about until, as he said, his legs began to fail, and then he lay on his back, according to the directions ..." (3). It seems strange that Socrates, who was charged in 399 BC as "an evil doer and a curious person, searching into things un­der the earth and above the heaven; and making the worse appear the better cause, and teaching all this to others" refused to contemplate the alternative to death, a fine. He who offered the philosophical argument that man is the property of Gods and must wait for their decision con­cerning the termination of life, chose to end his prema­turely by drinking a cup of hemlock.

Throughout history, those who supported and those who protested the act of suicide comprise a formidable list.

The pendulum of opinion swung in the opposite direction from that of and Socratic era three centuries later The Stoic school (founded in 108 BC in Athens by Zeno of Citium, exerted its greatest influence in the Roman empire) held the view that, given adequate reason, suicide is appropri­ate and perhaps required. Seneca the Younger, born nearly 2000 years ago, not only argued this position; he practiced it by electing to open his veins in 65 AD, when accused of involvement in a conspiracy against Emperor Nero whom he had taught.

St. Thomas Aquinas, the greatest of the medieval philosopher-theologians of the 13th century, pushed the pendulum back to the anti-suicide camp by preaching that suicide violates one's obligations to others and to God. Then David Hume, in the 18th century, expressed his alle­giance to Seneca's view that suicide is an honourable and sometimes praiseworthy act. However, his contemporary William Blackstone, while codifying the English law, categorised suicide as 'self murder' and a grave felony. For the past 250 years, these two schools of thought have split global society down the middle regarding the dilemma of suicide. In contemporary USA, Jack Kevorkian, a retired pathologist, who had assisted over 130 people to commit suicide, has brought the issue prominently into the public domain again (4-8).

With the 20
th century now over, newspaper headlines still report frequently about the rise in suicides in many countries. I speak with familiarity about two: Japan and Sri Lanka. I have been living in Japan for the past 13 years. Before the beginning of this century, the predominant sym­bols of Japan for outsiders were Samurai (with their characteristic suicide ritual of disembowelment, vulgarly known as hara-kiri among non-Japanese) and the geisha. During the second world war, kamikaze pilots, with their daredevil suicide acts, tried their best without success to turn the tide of war in favour of Japan (9).

In the postwar era, the man who characterised Japan inimitably to international audiences was Akira Kurosawa, the movie director, whom I consider as an intellectual descendant of Socrates. He mesmerised cinema fans world­wide with themes like truth and greed in human life, and did it wonderfully by adapting the literature of Shake­speare, Dostoevsky, Gorky and Akutagawa to the silver screen for nearly 50 years. American film maker Steven Speilberg hailed him a tribute as 'the pictorial Shakespeare of our time' (10). Though Kurosawa's end came naturally in 1998, at the respectable age of 88, he attempted suicide in 1971 at the age of 61, by slitting his wrist (11). Fortunately, he survived, w
hereas Kurosawa failed in his suicide attempt at the peak of his career, Juzo Itami (12), Kurosawa's junior contemporary and equally talented actor-movie director, who captured international attention with the satirical por­trayal of the anthropology of Japanese funerals in his movie Ososhikim 1984, succeeded in his attempt (13). In Decem­ber 1997, Itami ended his life by jumping from a highrise building in Tokyo. He became somewhat 'obsessed' with death following an assassination attempt a few years be-fore, which he survived miraculously. I inferred that Itami's cards were loaded against him. He was one of 23 494 sui­cides recorded in Japan for 1997. In 1998 the number of Japanese who committed suicide increased to 31 734(14).

Five years ago, a 198-page book titled Kanzen Jisatsu Manual (The Complete Manual of Suicide) authored by Wataru Tsurumi, became a runaway best seller in Japan (15). This happened despite the fact that the publisher refrained from widely advertising it when the book was released, and controlled sales by placing stocks in book­stores on the basis of advance orders. Like many other things exploited by the quick-buck minded hucksters in Japan, Tsurumi's book is an imitation of the 1991 contro­versial American best-seller Final Exit, authored by Derek Humphry, a co-founder of the Hemlock Society (16).

I was born in Sri Lanka at a time when it was known as Ceylon. Now as Sri Lanka, it holds the dubious distinction for the highest rate of suicide. In the span of 46 years since I was born, the suicide incidence in Sri Lanka has risen by over 1300% to vie strongly with Hungary (17), the estab­lished leader in suicides during our era.

Though it seems like yesterday, 40 years have passed since I was introduced to the reality of suicide. I was living as a child in a rural village, bordering the trunk road be­tween Mankulam and Mullaitivu, two sleepy towns of Ceylon, with my mother and maternal grandparents. One day, a telegram from Mannar was delivered to our house­hold, and I overheard the hushed talk which followed im­mediately among the elder members of the extended family. A little while later, my grandma began to sob. The protago­nist of that mournful telegram message, a niece of my grandma, had committed suicide. I came to know later that she was only 24 years at the time, having given birth to two charming girls - the younger one, then a mere toddler My aunt had taken the easy route to relieve her life's stress by drinking an organophosphorus insecticide, which was handily available in any farming household in Sri Lanka. That was my first painful introduction to the tragedy of suicide.

The news of suicide revisited me when I reached 12 years. This time, it claimed the life of one of my favourite teachers at secondary school, Canagaratnam "master". He probably had the strongest influence on my juvenile years from 1963 to 1965.1 still remember fondly how he anno­tated my homework exercises in English language with "Good" or "Very good". I yearned for those days when

Perspectives in biochemical sciences
Only I, among my classmates, was bestowed with those "Very good" credits. Not only English, but he also introduced me to Newton and his apple tree. We affection­ately referred to him as "cheroot Canagar" since he was fond of tobacco processed as a cigar. He was partial to arrack as well. He was an educator par excellence, who laughed at life's foibles and entertained students with his dramatic humour. He could also be a stern task master who freely used the cane when under the influence of arrack. We certainly dreaded his cane whacking our posteriors, but thrilled to his pontifications on how Newton did not think that the apple should fly above the tree. He kindled the flame of science in me. One day I heard he had commit­ted suicide by hanging. During my undergraduate days. I became convinced that alcoholic depression was the cause of his untimely demise. He was only in his thirties then.

Painful as it is to contemplate, how did I escape get­ting trapped in the suicide net in my late teens? Twenty-eight years ago, I failed twice in my attempts to enter the two medical faculties of Ceylon. Four years later, I failed to get even a low "second class" degree in zoology at my graduation. I
felt ashamed to face my teachers, friends and relatives. I have no doubt that I suffered at times such as these from a considerable degree of "psychache" which Edwin Shneidman (18), one of the foremost contemporary suicidologists, has labelled as a premonition of suicidal ideation. My failure to earn a "second class" degree de­railed my chances of becoming a permanent lecturer in one of the Sri Lankan universities. For 5 years I languished until I succeeded in receiving a graduate assistantship to one of the public universities in the USA.

In the past 25 years or so, neurochemists have specu­lated that low 5-hydroxy indoleacetic acid (5-HIAA) in the cerebrospinal fluid could predict suicide attempts and sui­cide (19-23). I count it as a blessing that my parents had endowed me with a proper blend of genes which code for an adequate, if not abundant, supply of 5-HIAA, the serotonin by-product, which is now gaining a reputation as a positive marker for depression and suicidal tendencies.

Deep in my heart, I also thank my mentor Canagatatnam "master" for teaching me by a sort of inverse demonstra­tion, that it is better to live rather than surrender one's life to stress. Socrates lives via Plato. It is not an exaggeration if I say that Canagaratnam "master" lives via me. That's why, I still get goose bumps when I read (albeit in English translation) Plato on how he experienced the ticking last moments of his menton Even after nearly 2400 summers, the pathos recorded in Plato's words moves me.

"The man who gave him [Socrates] the poison, now and then looked at his feet and legs; and after a while, he pressed his foot hard, and asked him if he could feel; and he [Socrates] said, 'No'; and then his leg, and so upwards and upwards, and showed us that he [Socrates] was cold and stiff And he felt them himself and said; 'When the poison reaches the heart, that will be the end'. He [Socrates] was beginning to grow cold about the groin. When he uncovered his face, for he had covered himself up, and said (they were his last words) - he said: 'Crito, I owe a cock to Asclepius; will you remember to pay the debt? ... " (3).

Sometimes I wonder whether Socrates is still having a laugh at the Athenian Democrats who tortured him (2). According to the commentary in Memorabilia by Xenophon, another disciple of Socrates, the Athenian gadfly was charged at his trial that he taught that it was folly to appoint the officers of the state by lot, "when nobody would dream of choosing a coxswain or a builder or a flute-player in such a haphazard fashion" (24). In the 2Y' cen­tury, America projects itself as the world's greatest democ­racy. But Ann Landers, the popular advice columnist to the American heart, has expressed concern about the in­creasing rates of teenage suicide in America. what she said 20 years ago still rings true. "Drug abuse, alcoholism, increase in violent crime, the ever-rising divorce rates, dis­integration of the family, pressure to engage in sex at an earlier age, competition for places in the so-called 'better schools'- all this has placed a great deal of added pres­sure on teenagers' (25). And suicide seems the easy way out of this misery for quite a significant number of teenag­ers in the USA (9,26). Even highly successful young Ameri­can role models (Marilyn Monroe, Kurt Cobain and River Phoenix, to mention a few) have sought the solace of sui­cide. Apart from the USA, suicide remains among the 10 most frequent causes of death in many other countries.

The 20th century is dying. But yet there is no "treatment' for suicide. The Global Burden of Disease Study (27) shows that in 1990, the number of suicides (786000) in the world far outnumbered deaths from HIV infection (312 000). But I have a hunch that one or more researchers who are contributing now to the understanding of the HW in­fection will stand a much better chance of being rewarded with a Nobel prize in the near future than someone who has done research on suicide.

References
1. Fant K. Alfred Nobel: A biography. New York: Arcade Pub­lishing; 1993: 258.
2. Nardo D. The trail of Socrates. San Diego: Lucent Books Inc; 1997: 8.
3. Plato. The trail and death of Socrates: Four dialogues. Un­abridged Greek text translated by Jowett B. Dover Thrift Edition, New York: Dover Publications; 1992: 55-115;
4. Roberts I, Kjellstrand C. lack Kevorkian: a medical hero (editorial). British Medkal Journal 1996; 312:1434.
5. Twycross R. Jack Kevorkian: a medical hero? British Medi­cal Journal 1996; 313: 227.
6. Gilbert J. Possibly a hero, but not a medical one.
British Medical Journal 1996; 313:227.
7. Rovner J. Kevorkian arrested on charge of first degree mur­der. Lancet 1998; 352:1838.
8. Brody H. Kevorkian and assisted death in the United States. British Medical Journal 1999; 318:9534.
9. Long K, Reim T. Fatal facts: A lively look at common and curious ways people have died. New York: Arlington House Inc; 1986: 88-107.
10. Prince S. The warrior's camera: The cinema of Akira Kurosawa Princeton, New Jersey: Princeton University Press; 1999: 3.
11. Sato T. Kurosawa Akira: a teacher of courage. Japan Echo 1998; 25:51-5.
12. Anon. Itami Juzo. Current Biography, 1990; 51: 304.
13. Anon. Director Itami leaps to death. Daily Yomiuri (Tokyo) 1997. December22.
14. Anon. Suicide numbers rocket as birthrate drops. Mainichi Daily News Tokyo) 1999. June 13.
15. Karasaki T. Parents, police concerned over suicide manual.
Asahi Evening News (Tokyo) 1994. April 9-10: p.7.
16. Manuk PM, Hirsch CS, Leon AC, Stajic M, Ranwell N, Portera L. Increase in suicide by asphyxiation in New York City after the publication of 'Final Exit'. New England Jour
nal of Medicine 1993; 329:1508-10.
17. Le Veechia C, Lucchini F, Levi F Worldwide trends in suicide mortality, 1955-1989. Acta Psychiatrica Scandinavica 1994; 90: 53-64.
18. Shneidman ES. The suicidal mind. New York: Oxford Uni­versity Press; 1996: ~l3.
19. Asberg M, Traskman L, Thoren P. 5-RIAA in the cere­brospinal fluid. A biomedical suicide predictor? Archives of General Psychiatry 1976; 33:1193-7.
20. Nielsen DA, Goldman D, Wkkunen M, Tokola R. Rawlings R, Linnoila M. Suicidality and 5-hydroxy indoleacetic acid concentration association with a tryptophan hydroxylase polymorphism. Archives of General Psychiatry 1994; 51: 34-8.
21. Lester D. The concentration of neurotransmitter metabo­lites in the cerebrospinal fluid of suicidal individuals; a meta­analysis. Pharmacopsychiatry, 1995; 28:45-50.
22. Mann JJ, Malone KM, Psych MR. Sweeney IA, Brown RP Linnoila M. Stanley B, Stanley M. Attempted suicide characteristics and cerebrospinal fluid amine metabolities in depressed inpafients. Neuropsychopharamacology 1996; 15: 576-86.
23. Asberg M. Neurotransmitters and suicidal behavior. The evi­dence from cerebrospinal fluid studies. Annals of New York Academy of Science 1997; 836:158-81.
24. Stockton D. The classical Athenian democracy. Oxford: Oxford University Press; 1990:176.
25. Landers A. The Ann Landers encyclopedia A to Z. New York: Doubleday & Co; 1978:1055-6.
26. Bell CC, Clark DC. Adolescent suicide.
Pediatric Clinics of North America 1998; 45: 365-80.
27. Murray CJL, Lopez AD. Mortality by cause for eight re­gions of the world: Global Burden of Disease Study. Lancet 1997; 349:1269-76.