Cultural Stigma Manifested in Official Suicide Death in South Korea

Abstract

This article examines the cultural sources of underreported suicide deaths in South Korea. It analyzes two sets of suicide data compiled by two different government agencies. Noting the considerable undercounting of suicide deaths compiled by the National Statistical Office, it explores how the underreporting is linked to the Confucian norm of familism. Despite an effort to improve the quality of official suicide data, a reform in the death system is needed in order to gather accurate data for a better understanding of the increased suicides as well as for the development of more effective suicide prevention and intervention strategies.

Keywords

stigma suicide death undercounting death system South Korea

Introduction

In November of 2005, a 26-year-old woman who was a daughter of Mr. Koh Choojang (anonymous), chair of a powerful South Korean conglomerate (chaebol), died by suicide abroad. The family’s spokesperson initially announced that she was killed in a car accident, but, due to the extensive foreign media coverage, the family later had to admit that the daughter’s death was the result of suicide (Baker, 2005; Cho, 2005). What is important to note was that the family’s omission of the true cause of death was acknowledged by the public as if the act of hiding the suicide fits a social norm, meaning that the public understood the feeling of pain and shame the family might suffer. After the admission of her death by suicide, the family did not speak publicly about the loss, nor did anyone else.

An effort to either withhold the information about a family member’s suicide or even falsely report it as a death by another cause is not an uncommon phenomenon in South Korean society. Such apparent cover-ups, which are observed beyond elite families as well, are chosen not because of any unlawfulness of the act of killing oneself—suicide was never been defined as an unlawful act in Korea. If illegality is not an issue, an important issue is why acts of suicide are often not acknowledged as suicides. This analysis considers whether a primary explanation for the underreporting of suicides is embedded in the culture of the society. In particular, we will look at the cultural context in which the act of self-destruction has been typically seen as a serious breach of the Confucian norms. In fact, it has been noted that families may not “wish to acknowledge suicide for fear of stigma or shame” (Hendin et al., 2008, p. 7). We will pursue this issue and ask whether Korean families, guided by such concerns, are influenced in reporting causes of death by a fear of a stigma that the society can attach to suicidal behavior. The fear of stigma and shame could influence not only the actor but also the actor’s family as well.

Any attempt to avoid such a stigma would have the effect of being an informal barrier that naturally affects the official counts of suicide mortality. Significant issues of public policy are involved in any underreporting of suicides. Among the consequences of such underreporting could be a public perception that suicide deaths are less significant in South Korea than is actually the case. Also to the extent to which the Korean government is prevented from generating more valid official data on suicide, the result would be a significant reduction in its usefulness in implementing and evaluating prevention and intervention programs (Im et al., 2008).

The Confucian cultural legacy that still profoundly affects many aspects of people’s lives in modern Korean society is largely a sociocultural force that prevents the Korean government from carrying out important policies. An accurate counting is vitally important not only for a better understanding of public health issues but also for developing adequate prevention policies (De Leo et al., 2010; Douglas, 1967; Lester, 2002; Rockett, 2010; Rockett, Kapusta, & Bhandari, 2011).

Culture is highly relevant in understanding not only the cause of suicide but also its prevention (Colucci & Martin, 2007; De Leo, 2002; Lester, 1997). However, little research has been conducted on how specific cultural meanings, interpretations, and mental representations of society are linked to suicidal behavior. Herein, acknowledging that sociocultural factors can become an impediment in obtaining accurate information, we explore how the traditional Confucian cultural norm of filial piety is manifested in death ascertainment procedures and the resulting underestimate of suicide deaths in South Korea.

This article thus aims to understand the cultural meaning of suicide, which elicits fear of stigma and shame in the contemporary Korean cultural context. We will first assess the quality of suicide mortality data for the period of 1999 to 2005 compiled by two Korean government agencies, namely the National Statistical Office (NSO) and the National Police Agency (NPA). Noting the significant undercounting of the suicide death in the government official data set compiled by NSO, we explore some aspects of the Confucian legacy as a prevailing social force that contributes to the underestimation of official suicide mortality. Acknowledging that valid and reliable data are vital to accurately gauge increased suicide behavior in modern Korea and to develop appropriate prevention or intervention policies, we suggest ways to improve accuracy in the process of counting of suicidal deaths.

Reliability of Suicide Data

Official suicide statistics generated by the NSO are based mainly on the cause of death data gathered from death notification cards filed by spouses, family members, or friends of the deceased. The undercounting of official suicide data stems, in part, from the death system that lets family or friends fill out the death notification card. In addition, other sources of information, such as an autopsy, are significantly underutilized. A death certificate issued from the hospital is then attached to a death notification card. The doctor’s diagnoses can be included in the death certificate when the deceased is under a physician’s care. These diagnoses are critical in determining the true cause of death. However, according to Jae-Ho Suk (1992), only approximately 30% of the total registered deaths in 1986 comprise doctor’s diagnoses, excluding the medical examiner’s inquiry which is conducted only in cases of suspect or unnatural deaths. In a recent study designed to evaluate the quality of death statistics, Park et al. (2003) similarly discovered in 2,986 cases of registered death in the Cheonan-Asan region of Korea that 37.3% consisted of doctor’s diagnoses, 26.4% of medical examiner’s certificates, and 36.3% of death registration without a medical proof of death.

Another source of suicide data is compiled by NPA and is based on the criminal information management system (CIMS) that records in text format all reported deaths from accidents and suicides. The data do encompass foreign-born nonresidents because it is derived from field investigations, including descriptive accounts by detectives based on affidavits from family members, neighbors, or friends of the deceased, and autopsy reports as needed. What is lacking in the data set is the standardized, prearranged classificatory system. That is, some cases have rich detailed facts but others are deficient with information such as methods of suicide because of the detective’s arbitrary decision to take notes.

As shown in Figure 1, the number of suicides reported by the NPA is generally higher than that of the NSO. For example, the annual gap in the compiled number of suicides from 1999 to 2002 between the two agencies ranges from 4,000 to 5,000. This significant continuing difference strongly suggests the undercounting of official suicide statistics as compiled by the NSO. It was suspected that, as elucidated above in Koh’s family, many cases of suicide might be falsely reported on the death notification card. Acknowledging the unreliability of information on the death notification cards the NSO, since 2003, has cross-checked their statistics with data compiled by the NPA and made appropriate adjustments to the official suicide data. The process involves a cross-examination of cases in the NSO’s mortality data with the same case in the NPA’s CIMS. The goal is mainly to identify a discrepancy on the recorded cause of death using the resident registration number including the name of the deceased person and the address. For instance, if traffic accident was recorded as the cause of death on the NSO’s mortality data, while the NPA’s data recorded the death caused by suicide, a correction on the NSO’s data would be made.¹

Figure 1.

The number of suicide in Korea, 1999 to 2005.

As shown in Figure 1, although the gap had narrowed since 2003, approximately 2,000 cases of suicide each year appear to be excluded from official NSO suicide data,² which remained largely as ambiguous (typically known as undetermined) cases of death. Thus, as the undercounting of suicide is estimated to be about 10% to 20% in European countries (Varnik et al., 2010), it is reasonable to assume that substantially more suicides are undercounted in Korea’s official suicide mortality data.

Given the social context in which suicide becomes shameful to one’s family, it is plausible to infer that some families, particularly those occupying the upper-socioeconomic strata, such as the Kohs, employ their prestige and power to make physicians feel reluctant to record the cause of death as suicide on medical certificates. The result of the fear of stigma and shame has been a considerable undercounting in Korea’s official suicide statistics. What follows is a brief discussion of the role of culture in the formation of positive and negative meanings of suicidal acts.

Cultural Meaning of Suicide

The shared meaning of suicide in Korea has been largely shaped by Confucianism, the ideology that was practiced over a thousand years ago and remains strong in Korean society. It is thus important to explore the legacy of Confucianism, albeit briefly, in order to better understand the reason why many Korean families wish to hide a family member’s suicide. Unlike in the West, suicide in Korea has never been defined as a criminal or moral offense. In fact, suicide has not been viewed as “intrinsically wrong” (Lo, 1999, p. 74). In some situations, the act of purposefully killing oneself for noble causes, or as an effort to preserve one’s honor or integrity, has been viewed rather positively. People who have committed this type of purposeful death as a way to send symbolic or political messages were often portrayed as martyrs in the country (Park, 2004, 2013). However, it is important to note that the nonpurposeful, purely personally motivated suicide that Durkheim called egoistic is regarded negatively. That is, any act of killing oneself motivated by personal reasons can be viewed as a sign of deficiency in personal moral character, which may be linked to the upbringing by one’s family. A few Confucian ideas are central to this negative evaluation of egoistic suicide.

The overarching virtue intrinsic to the Confucian teaching is the capacity to love (ren仁, benevolence or humanity). In particular, this virtue of love is an essential moral characteristic for a person wishing to be a leader. Yet, this moral characteristic is not an inherent trait but attained through self-cultivation. It is believed that the morally cultivated person would know how to live ethically, which ultimately would lead to building a peaceful and flourishing society. Thus, cultivation of the moral self is the way to build a good society.³

The family, Confucius believed, is the single most important social institution in which one’s self-cultivation takes place. Relations between parents and children are exemplary relationships in which parents display benevolence, and the children learn how to relate to others in the broader world. Children are, in the process of developing moral character, required to uphold “filial piety” because it is, as Confucius argues, “the root of virtue and the origin of instruction” (Goldin, 2011, p. 35). The display of gratitude and respect for parents are the primary way to attain these virtues and, ultimately, a greater capacity to love others.

More importantly, filial piety is not limited to a temporal reverence of one’s own parents but extends to a religious obligation toward one’s ancestors (Lew, Choi, & Wang, 2011). In the Confucian family, the ritual and what some call ancestor worship (Deuchler, 1992) is performed by the father in order to honor their ancestors. This ritual also functions to “ensure the family’s continuity across the generations” (Hahm, 2004, p. 99). Consequently, the ancestral memorial ceremony makes the living generations in the family (or in the clan) remember and represent their ancestors, which includes their own parents: “Through remembrance and representation of descendants, death is transformed into immortal life” (Lew et al., 2011, p. 176). The religious meaning that the Confucian family carries provides individual members with not only a clear sense of identity but also a moral imperative. However, individual members “exist as parts constituting the whole in the form of family – that is, as unity, not as independent units” (Lew et al., 2011, p. 180).

Thus, from the perspective of filial piety, self-harming behavior or suicide can be regarded as more than “usurping the authority of parents” (Lo, 1999, p. 79). It is the defilement of the sacred cultural rule of familism, as well as the desecration of one’s own ancestors. As discussed earlier, only the altruistic type of suicide that is committed to obtaining a high moral significance can be accepted. Unless the act of killing oneself involves “a protection of one’s dignity, honor or integrity,” it is generally condemned (Fei, 2009, p. 16). In this cultural context, the death of a child by suicide causes parents to experience not only feelings of loss but also a deep sense of shame. A man of virtue is not supposed to kill himself for personal reasons. Such suicide thus carries a stigma not only for the individual who committed the act but also for the family because it signifies moral failure in fostering appropriate values, as well as providing discipline in cultivating a man of virtue. This negative cultural meaning that is attached to the egoistic type of suicide in contemporary Korean society, in which the legacy of the Confucian norm of familism is widely pervasive, leads many people to hide this type of suicide from the public. In this cultural context in which the Confucian legacy is still a strong moral force in the lives of most Koreans, the reporting a suicide as death by another means could be considered as a strategy to avoid stigma or shame attached to one’s family.

Improving the Quality of Suicide Data

This resulting underreporting of suicides compiled by the NSO gave rise to serious questions regarding the quality of official statistics in Korea. In response to this question of reliability, the NSO has made an effort to improve the quality of suicide data by cross-checking since 2003 its data with the data compiled by the NPA, which is based on the CIMS. Still, the existing discrepancy between NSO and NPA data sets, as discussed earlier, suggests a continued underreporting of suicide. Furthermore, the NSO data leave unexamined the hidden intent of some deaths including ones caused by different means, such as using an automobile as a method to kill oneself. Under the current NSO reporting system, it is not possible to identify the intent of the deceased. For instance, if a death is caused by drowning after being intoxicated, should it be classified as an accident or a suicide? More importantly, given the cultural prejudice, some of the physicians, dentists, and oriental medicine doctors who would sign the death certificate might feel reluctant to certify a death as a suicide because of the survivors’ social positions (De Leo, 2010; Rockett et al., 2011). Lester (1994) found in his study of the classification methods among 17 nations that suicides were hidden within the category of undetermined or disguised as accidental deaths, which affected official statistics on suicide in some countries. Rockett et al. (2014) contend further that having categories of accidental or undetermined intent in cases of drug self-intoxication death creates both conceptual and data problems in suicide research.

In South Korea, Im et al. (2008) examined cases that were initially compiled on the death notification card as a cause of death other than suicide but were later corrected to show suicide as the cause. Of the total 32,496 cases of suicides (excluding the 410 cases of foreign-born nonresidents) during the period of 2004 to 2006, they found that 38.5% of cases (n = 12,510) consisted of false reporting. Of those cases, the most false reporting (61%) was found among those without doctor-issued death certificates. Still, a sizable number of cases (about 30%) with the doctor-issued death certificate involved false reporting. In their analyses of characteristics of falsely reported cases as shown in Table 1, they found that false reporting was more likely to occur among suicides committed by females (1.13 point higher vs. male) and married people, and false reporting increased with age. The increase in false reporting by age was particularly marked for elderly people, for whom honor to the surviving family members was seemingly more at stake than among families of younger persons. In regard to the method of suicide, the largest false reporting (74.4%) was found among traffic accidents followed by burning and falling where the accident, and not intended suicide, was originally recorded as the cause of death.

Table 1.

Multivariate Analysis of the Characteristics of the Falsely Reported Cases in South Korea, 2004 to 2006 (n = 12,510).

Variable	Classification	OR	95% CI
Gender	Male	–	–
	Female	1.132	[1.080, 1.186]
Age	19 and younger	–	–
	20–29	1.089	[0.935, 1.269]
	30–39	1.031	[0.886, 1.201]
	40–49	1.139	[0.976, 1.328]
	50–59	1.211	[1.034, 1.418]
	60–69	1.268	[1.083, 1.486]
	70–79	1.508	[1.285, 1.770]
	80 and older	1.689	[1.428, 1.998]
Marital status	Married	–	–
	Single	0.851	[0.757, 0.956]
	Divorced	1.293	[1.113, 1.475]
	Widowed	1.030	[0.899, 1.180]
	Unknown	0.920	[0.672, 1.260]
Diagnostician	Physician		–
	Oriental doctor	0.878	[0.472, 1.632]
	Others	3.225	[2.452, 4.241]
	Unknown	0.000	[0.000, 0.000]
	No document	1.057	[0.966, 1.157]
Suicide method	Strangulation	–	–
	Traffic accident	8.289	[6.495, 10.578]
	Poisoning	1.877	[1.786, 1.973]
	Falling	5.442	[5.109, 5.796]
	Burning	6.058	[4.916, 7.467]
	Lethal weapon	1.658	[1.376, 1.998]
	Others	3.210	[1.092, 9.438]
	Unknown	0.677	[0.581, 0.787]

Source: Im et al. (2008, p. 40).

The prevailing cultural stigma toward suicide behavior serves as a major barrier to the current system of counting deaths by suicide based on death notification cards. Although the NSO, a government agency that compiles the official suicide statistics, has improved the quality of data since 2003 by recognizing falsely reported cases through cross-checking with the data assembled by the NPA, it is not apparently sufficient enough to generate an accurate picture of self-destructive behavior in the country. Even with the cross-checking, roughly 15% to 20% of ambiguous (typically referred to undetermined) cases of suicide recorded on the NPA’s CIMS could not be confirmed on the NSO’s death registry system where they were considered as underestimated suicides.⁴ These undetermined cases being apparent after cross-checking, not to mention about the hidden intent in the death system, still poses a concern about the validity and reliability of official suicide statistics. Accurate suicide data are crucial in order to achieve a better understanding of rising suicide rates in contemporary Korean society, especially when the official suicide rate had a fourfold increase over just two decades from 7.3 per 100,000 people in 1991 to 31.7 in 2011 (see Figure 2). Without accurate suicide data, the goal of reducing suicide rates will be limited. For example, it is rather difficult ascertaining “whether a particular mental health program has had an impact on the suicide rate” (Lester, 2002, p. 133) if the suicide rate data are so inaccurate.

Figure 2.

Trends in suicide in Korea.

We see the need to change the current less-rigorous death ascertainment procedure as a way to improve the quality of suicide data. Currently, a physician attending a patient at the time of death (or evaluating a death within 48 hours) fills and signs the death certificate. We suggest that the death certificate be required following every death. When there is no physician to sign the death certificate, instead of having verification presented by family, relatives, friends, or neighbors, the cause of death should be determined by a medical examiner or a coroner. We strongly believe that the coroner system that certifies and investigates the manner and cause of death, as practiced in many other countries but not in Korea, needs to be implemented. This coroner system may not eliminate all cultural biases on suicide death, but it would reduce cases of false reporting as well as undetermined cases. An autopsy would also enhance the quality of suicide mortality data in cases of suicide disguised as accidental deaths. Nevertheless, given the cultural context in which preserving the body intact, even in death, is seen as a form of filial piety, enforcing an autopsy would encounter familial resistance. As Kapusta et al. (2011) found in a longitudinal, cross-cultural study of 35 nations, countries with the reduction in autopsy rate faced declining suicide rates and an increase in undetermined deaths, which demonstrates that an autopsy enhances both the accuracy and the quality of suicide mortality data. However, an attempt to make an autopsy compulsory in death-ascertainment procedures could prove controversial in the Korean cultural context.

Coroners and medical examiners would improve the quality of suicide data by not only accurately classifying it but also investigating the intentions of the deceased. As discussed earlier, the current death notification card or death certificate has no procedure that queries the intentions of the deceased. For instance, given that Koreans often over-consume alcohol, if an intoxicated person jumps into a swimming pool and drowns (or is killed by an automobile accident), the death should be investigated for the actor’s motivation.

Currently, NSO collects data on both methods and locations of suicide, while the NPA’s CIMS stores information on cause of suicide based on the set of 11 items.⁵ Certainly, it would improve the quality of data if there were a way to combine these two sets of data. However, for a variety of reasons including the use of text format in the NPA system and incompatible classificatory systems, Im et al. (2008) found that combining the two data sets would be impossible. Therefore, it would be necessary for both agencies to use, even in a modified form, the International Classification of the External Causes of Injuries proposed by the World Health Organization in 2001. It is also understandable that culture can be a prohibiting factor for gathering quality suicide data. For instance, Koreans are reluctant to discuss or reveal any issue that deals with family discord or conflict with friends or fiancés. Thus, information gathered from death notification cards might not be highly reliable, even if it is required to report the true cause of suicide.

Implications of the Current Trend in Suicide

Thus far we have discussed the tendency for Korean people to suppress information on suicide, a practice which is deeply imbedded in its traditional Confucian culture. However, in the modern era in which the society has experienced a fourfold increase in official suicide rates over the period of just two decades, the desire for privacy is conflicting with the public need for obtaining quality data to better understand and develop effective prevention strategies. In response to this serious public health issue, federal lawmakers passed a bill in 2011 that aimed at suicide prevention and intervention. As a result, various programs have been developed to reduce suicidal behavior in the country. However, it is important to note here that suicide behavior takes place in a sociocultural context (Kral, 1998). An effective suicidal prevention program thus should be relevant to indigenous cultural values or norms (Colucci, 2009; Hjelmeland et al., 2006; Hjelmeland & Knizek, 2004) because cultural meanings are important not only for understanding factors shaping suicidal behaviors such as suicide attempt and completed suicide but also for developing prevention or intervention strategies (Colucci, 2013; Colucci & Martin, 2007; De Leo, 2002; Lester, 2013).

In particular, previous studies focusing on the role of public attitude toward suicide found a positive linkage between suicide acceptability and suicide behavior on both individual and aggregated levels (Agnew, 1998; Cutright & Fernquist, 2004; Joe, Romer, & Jamieson, 2007; Park, Im, & Ratcliff, 2014a, 2014b; Stack, 1998; Stack & Kposowa, 2008, 2011). Park (2013) argues that while cultural stigma may not serve as a significant force deterring suicidal behavior, changing cultural processes in modern Korea, along with individual pathology, may be contributing to such a sharp increase in suicide deaths. What Park (2013, p. 237) refers to as “collective cultural ambivalence” that comes along with the pressure to integrate into the neoliberal economic system becomes a major force making Korean society experience social disorganization (Cavan, 1965). This cultural context, Park (2013) argues, can lead more individuals to experience confusion or conflict in regard to social expectations, thus to feel failure either perceived or real to adapt to the changing cultural environment and to the shifting social relationships. These individuals are then susceptible to psychosis, such as depression, which can lead to suicidal behavior (Cavan, 1965; Park 2013). Moreover, Park et al. (2014b) found based on the 2009 General Social Survey data, comprising of a national sample of 1,599 Koreans (aged 18–94 years), that the survivor status was a risk factor for suicidality. Their analysis suggests that people who had exposure to their family members’ or close friends’ completed suicide, suicide attempts, or even suicidal thoughts, were more likely than nonexposed individuals to develop depressive symptoms and approving attitude toward suicide (particularly for females) which then made them more vulnerable to suicidal ideation or suicidal behavior. Similarly, such results were found in other studies (Abrutyn & Mueller, 2014; Bronisch & Lieb, 2008; Melhem et al., 2007; Qin, Agerbo, & Mortensen, 2003; Saarinen, Hintikka, Lehtonen, Lonnqvist, & Viinamaki, 2002), which suggest a signficant subcultural effect.

Based on the findings of previous studies suggesting that the cultural dimension is an important force in shaping an individual’s suicidal thought and behavior, we believe that an effort to change public attitudes about suicide would be an effective approach not only to remove the barrier in producing quality official data on suicide but also in enhancing public knowledge that enables those suicidal individuals to receive appropriate help. Previous studies show that the individuals suffering from depression who hold a high level of stigma toward mental health are less likely to seek help for their depression (Barney, Griffiths, Jorm, & Christensen, 2006) and that providing psycho-educational material brings about decreases in stigma on mental health (Griffiths, Christensen, Jorm, Evans, & Groves, 2004). Building on these studies, community-based research using an online survey with 1,286 adult participants in Australia was conducted to see whether greater knowledge about suicide would lead to less stigmatizing attitudes in the general population (Batterham, Calear, & Christensen, 2013). The researchers found that, in contrast to the findings on mental health stigma, individuals with suicidal ideation hold less suicide stigma, nonetheless, more glorification of suicide than those of little suicide ideation. Still, overall findings lead the researchers to suggest that the combination of deficits in knowledge about suicide, high stigmatizing attitude, and glorification of suicide acts may hamper help-seeking behaviors in general population. Thus, they argue that “suicide literacy and stigma reduction programs” could be effective for suicide prevention (Batterham et al., 2013, p. 415).

We also believe that what they refer to as a stigma reduction program may be an appropriate program that increases public knowledge and reduces stigmatizing attitude toward suicide given the cultural context in which the agriculture-based Confucian values and beliefs have been incongruent with the neoliberal economic structure in modern era. Such programs can empower people to have control over their life through understanding of ambiguities regarding social expectations and learning various ways to adapt to shifting contemporary social relationships. People can also be informed on how to deal with their emotion such as a sense of guilt or shame. Relevant emotions would also include feelings of inadequacy that arise as a result of deviating from an internalized norm, such as filial piety. People would hopefully learn how to reinterpret the traditional values to make their contemporary living more meaningful. More importantly, a stigma reduction program can educate people not only to blindly expect external social norms to guide them in this modern, complex, diverse, and organic social world but also to build internal moral or ethical standards on behalf of personal rights instead of obligation, meaningful social relationships instead of mechanical bonds, and self-preservation instead of self-sacrifice.

As stated earlier, the public policy need is to obtain valid and reliable suicide data in order to assure success of prevention or intervention programs. Yet, without an attempt to change public attitudes toward suicide, an effort to more thoroughly examine the possibility of classifying a death as a suicide would potentially encounter resistance from the anguished families. Thus, as a way to reduce the tension between public policy goals and the desire for privacy, a stigma reduction program is necessary. It is important to note that such a program is essential not only to decrease the stigmatization of suicide but also to increase public knowledge about suicide. Such an increase can lead to the help-seeking behavior for those potentially suicidal individuals, which would contribute to the reduction of the currently high suicide rates in Korea.

Conclusion

This article represents an attempt to understand the cultural source of the phenomenon of underreporting of deaths by suicide in South Korea. The origin of the prevailing fear of stigma or shame that lies in the Confucian norm of filial piety was discussed. Although there is no specific prohibition of suicide in Confucianism, the act, if egoistic, is considered dishonorable not only to the actor but also to parents, as well as to the ancestors. Because suicide is regarded as a moral blemish, any Korean family, particularly an elite family, will not disclose the true cause of death. The legacy of Confucian familism is the principal cultural force that induces false reporting on the death notification card, which is mainly filled out by surviving family members.

A significant improvement was made by the NSO’s official suicide data since 2003, but we see more effort is needed to produce accurate information for a better understanding of increased suicidal behaviors and for developing effective prevention and intervention strategies. Further improvement could be made by implementing the coroner system in the death-ascertaining procedure. We acknowledge that culture can also impede the redesigning of a system that would more effectively gather relevant and accurate suicide data. However, given few means to fight the cultural stigma, we suggest the implementation of a revised system to reduce cultural biases and the requirement of a medical examiner or coroner to determine the cause of death other than those attended by the physician within the duration of 48 hours. Such a reform in the South Korean death system would enhance the verity of scientific investigations into the motivations of egoistic suicide.

While the result of such changes would be more accurate statistics, it can also be expected that there would be some resistance to the demand for such greater thoroughness of information. The issue is that those who have lost a family member would not welcome a potentially intrusive examination of the possibility of suicide. For the very reasons discussed in this article, a family might prefer that fictions about the nature of the death be maintained. The potential advantages of better statistics need to be balanced against the prospect of great anguish in the families. To deal with the potential conflict between public policy goals and private concerns, we propose a cultural education program such as what Batterham et al. (2013) refer to stigma reduction program that can help people deal with inner conflict arising from the gap between internalized Confucian values and modern neoliberal market values. Such a program can not only educate about the importance of gathering valid and reliable suicide statistics in order to properly respond to this serious public health issue facing Korean society but also increase public knowledge about suicide, thereby helping suicide-prone individuals seek necessary assistance.

Footnotes

Notes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Jeong Soo Im is a professor of Epidemiology in the Department of Preventive Medicine at Gachon University School of Medicine in South Korea. He currently serves on the director of Cancer Survivorship Program at the Incheon Metropolitan Regional Cancer Center. His research also focuses on suicide prevention/intervention strategies.

B. C. Ben Park is a professor in Human Development and Family Studies at Pennsylvania State University, Brandywine. The major strand of his research has focused on politically motivated suicide as well as other types of self-destructive behavior. His recent research focuses on the link between culture and suicide.

Kathryn Strother Ratcliff is a faculty member and associate head in the Department of Sociology at the University of Connecticut. Her research area is the sociology of health. She has published a book, Women and Health: Power, Technology, Inequality, and Conflict in a Gendered World and written articles on Globalization, Women, and Health; Midwifery; Health and Human Rights; Poverty and Health; and suicide in South Korea. Her new book, Social Determinants of Health: Looking Upstream, is scheduled to appear this year.

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