Abstract
Attempted suicide is still criminalized in Uganda. However, the Ministry of Health has asked the psychiatric community to help in the work to abolish this law. The purpose of this study was to investigate how Ugandan mental health workers view this law. We conducted a qualitative interview study of 30 mental health workers (psychiatrists, psychologists, psychiatric clinical officers and psychiatric nurses). We found that two-thirds of this sample wanted the law abolished, mainly because they view suicidal behaviour as a mental health issue. Some, however, wanted to keep the law because they viewed it as a suicide prevention in that it would deter people from killing themselves. A few were ambivalent. The findings indicate a need for increased awareness of the negative consequences of the law as well as educating mental health workers in understanding of suicidal behaviour and suicidal people.
Introduction
In Uganda, attempted suicide is still criminalized. In the Penal Code Act Cap. 120 under ‘Chapter XX – Offenses related to murder and suicide’, paragraph 210 reads: ‘Any person who attempts to kill himself or herself commits a misdemeanour’ (p. 109). A misdemeanour is punishable by imprisonment for two years. However, the World Health Organisation (WHO) has stated that laws criminalizing suicidal behaviour have a number of serious negative consequences, for instance, mandatory police investigation and court judgements which may lead to hospitals refusing to admit persons who have attempted suicide. 1 The consequences are refusal to help people in need or concealment of facts (that is, admit them for other reasons), gross underreporting and increased stigma (due to police visits). As a result, vulnerable people do not receive proper medical and/or psychiatric help. 1 Furthermore, the WHO emphasizes that most developed countries have decriminalized suicidal behaviour and urges legal authorities in countries that have still not done so to take responsibility: ‘Legal authorities need to be made aware of the consequences of such laws and their role in making services easily available, decreasing harassment and the burden on individuals and eliminating stigma. A greater interaction between law-makers, enforcing agencies and health professionals is required for a smooth transition towards a new phase’.
Indeed, the Ministry of Health in Uganda is interested in getting the law criminalizing attempted suicide abolished and has asked the psychiatric community to establish dialogue with the Law Review Commission so that they can start to change attitudes in this regard (Dr. S. Ndyanabangi, Principal Medical Officer in charge of mental health at the Ministry of Health in Uganda, personal communication, April 2011). There is, however, some resistance in the juridical community since many of the legal professionals believe that keeping attempted suicide criminalized is suicide preventive. Since the psychiatric community is expected to play a central role here, it is important to first study mental health workers’ views on this issue. The purpose of the present study was therefore to investigate how Ugandan mental health workers view the law criminalizing attempted suicide.
Method
We conducted semi-structured qualitative interviews with 30 mental health workers in Kampala, the capital of Uganda; psychiatrists (n = 10), clinical psychologists (n = 5), psychiatric clinical officers (n = 8) (a psychiatric clinical officer is a psychiatric nurse or general medical clinician with an additional two years training in psychiatry [diploma in psychiatry]) and psychiatric nurses (n = 7). Fifteen men and 15 women were interviewed and both genders were represented in all groups. Among a number of other issues related to suicide and suicide prevention, the informants were asked to share their views on attempted suicide being criminalized by law in Uganda. The interviews were conducted at Butabika and Mulago hospitals. All interviews were tape-recorded and transcribed verbatim.
Analysis
The data were analysed by thematic content analysis. 2 First, the responses were categorized with regard to the informants’ views on the criminalization of attempted suicide. Second, the reasoning behind each of the standpoints was analysed in depth with the aim to provide some basis for educating relevant groups as well as to provide arguments to aid the work of abolishing the law. The first author did the initial categorization, which was then discussed in the research group until consensus was reached.
Ethical issues
The study was approved by the Regional Research Ethics Committee in Central Norway as well as the Uganda National Council of Science and Technology. There are few psychiatrists and even fewer clinical psychologists in Kampala (30 and 10, respectively, in the entire country in the year of the study, 2008). 3 Since the second author (Ugandan psychiatrist) is their colleague, some were worried about anonymity and confidentiality when interviewed on such a sensitive topic. To maintain the informants’ anonymity with regard to their close colleagues, all the interviews were conducted by the first and last authors, (Norwegian psychologists not working in Uganda) and transcribed in Norway. To further preserve anonymity, the results are not presented by profession or gender.
Findings and analysis
All except one of the informants knew that attempted suicide is criminalized in Uganda. About two-thirds of the sample took the clear standpoint that this law should be abolished, whereas some took an equally clear standpoint that the law should remain in place. Some were ambivalent regarding the law, and one wanted it changed, but not removed. The reasoning behind each of these standpoints is outlined and discussed subsequently.
Reasons to abolish the law
The reasons for removing the law were mainly that the mental health workers saw suicidal behaviour as a result of pain or mental or other problems that required help. For instance, one informant said: ‘…they feel – it's just pain. Somebody's having pain. And then you are – imprisoning him or her. With the pain, it appears you would not have helped’. Another informant emphasized mental illness as central in suicidality: ‘Ideally he is sick. Mentally. We shouldn't – we shouldn't consider him or, you know – being condemned’. A third informant also pointed to mental problems as the core of suicidality, but in addition emphasized that other problems may make some people suicidal: ‘Cause these people, like, for example, somebody who has – a psychiatric problem (…) And even this one who has other problems like maybe social economical problems. Because has not got somebody – to help him or her. So he thinks this is the only solution…’ These informants emphasized that suicidal persons need help that they are not likely to receive in prison. One informant saw attempted suicide as a direct cry for help: ‘Because, I feel, instead of this person being taken to prison, this person should be – brought to psychiatric hospital for help, because – to me, it's like, someone is crying for help. And it's not there. So they should be brought to psychiatric hospital’. ‘Cry for help’ is a common interpretation of one of the intentions involved in suicidal behaviour in the suicidological literature. 4 Although most informants saw attempted suicide as a consequence of mental illness, as illustrated above, some saw it as a sickness in itself as exemplified with the following quotes: ‘It's – mental illness’, or ‘Cause it's an illness. Just like any other illness’, or ‘Because it's not a crime honestly. It's a sickness’.
In keeping with the WHO's emphasis on the potential consequences of criminalization of suicidal behaviour pointed out above, some informants said that as long as suicidal behaviour is criminalized by law, people might be afraid to seek help. In the words of one informant: ‘Because – at the end somebody attempts suicide, because it's been criminalized, people may fear to - take such a person out in order to avoid the person to be criminalized’. In other words, family or friends may be afraid to seek help for a suicidal individual because they are afraid of the legal consequences for the person, a view in keeping with that of the WHO. 1 Extensive research in the Western part of the world has identified attempted suicide as the most important risk factor for completed suicide. We do not see any reason why this should be different in Uganda. Thus, it is crucial that suicide attempters receive proper help with the problems leading to their suicidality. Decriminalizing attempted suicide will increase the chances of them getting help.
Reasons to keep the law
The main reason for keeping the law in place was that it was believed to be suicide preventive as exemplified by this voice: ‘…I think – attempted suicide – should be a crime – because – it would help us, you know – it would help prevent – suicide’. The explanation was that it would deter or even scare people from attempting suicide. One informant claimed that in a developing country it really was necessary to criminalize suicidal behaviour, because people there only fear the law. Another informant strongly believed that strict punitive measures would be preventive: ‘I'm looking at these people, who – attempt. But if there are very strict punitive measures in place, then they would desist from – ever thinking of attempting’. This informant emphasized that the law would be particularly effective in scaring young people into never attempting suicide.
Some saw imprisonment as a safety precaution for the suicidal person as illustrated by this informant: ‘…to safeguard this person in that very community – may be very difficult after receiving treatment here [the psychiatric hospital]. The only – custody – may be keeping this person temporary in the – prison. Because sometimes, our communities are violent. The moment you are treated from – this, here – you go back to the community – the same – factor – may be imposed on you. And then you find that it, there are high chances for you to – commit suicide.’
This informant is implying that factors in the community may have made the person suicidal and that when the person comes back to the community after having been treated in the psychiatric hospital, the same problems continue and the person may end up killing himself. The informant might also be alluding to some of the negative attitudes towards suicidal people that have been found in some communities in Uganda 5 and also to the stigma attached to being treated at a psychiatric hospital. This informant also meant that out in the society you might be alone, whereas in prison you are with many people and thus you will be prevented from harming or killing yourself. Indeed, prisons in Uganda are known to be extremely overcrowded. 6 However, we have little reason to think that suicide attempters will receive the necessary help in prison.
Ambivalence with regard to the law
Some informants were ambivalent with regard to the question of whether attempted suicide should remain criminalized. They tended towards the view that it should not be criminal if it was in relation to mental illness, but if it was not, it should be considered a criminal offense. Another view expressed was that the law should be kept in place but that it should be an assessment to see whether the suicide attempter could be regarded to be criminally responsible or not. For instance, in the words of this informant: ‘But ideally – if somebody has committed suicide out of mental illness, it's supposed to be treated and maybe – to me, to be allowed free (…) It should be a, anyway as a criminal offence, but now, when it comes to the time of assessment – there should be a judgement, whether this person did it … whether he is – criminally responsible or not. That judgement should be there (…) The law should be there, because I'm not – everybody who commits suicide may not be having – mental problem …’
This view resonates with a view that was common in Europe several hundred years ago when suicide was commonly regarded as a sin against God or the sovereign (i.e., a crime) and from the mid-eighteenth century when the ‘medicalization’ of suicide was beginning to appear. 7 In the words of MacDonald and Murphy: 8 ‘…one was either a criminal and a sinner, or mad. The guilty self-murderer had to be capable of premeditating his crime, thus “idiots and lunatics” were spared the penalties associated with a verdict of felo de se’ (pp. 15–16).
The informant above talks about ‘committed suicide’ rather than ‘attempted suicide’. Several informants actually talked about ‘committed suicide’ when they seemed to mean ‘attempted suicide’ since they talked about the treatment those who had ‘committed suicide’ received when they were admitted to the psychiatric hospital. Whether this is just a mix-up of concepts or a deliberate choice of words to emphasize the criminal connotation carried by ‘committed’ (as in commit a crime) is, however, difficult to ascertain. In hindsight, this should have been clarified in the interviews.
The law should be changed
One informant believed that the law should be changed, but not removed, because then we might lose the suicide attempters. The law should therefore be changed to indicate that they should receive help: ‘Changed, I think, so that – another law should be put in place, so that these people get help (…) What I mean is – people who attempt to commit suicide – the, problem should be addressed. Somehow. So if the law is removed – then we might totally lose them’. This informant seems to be arguing for a law securing treatment for suicide attempters. Some countries, for instance, Japan, have actually implemented legislation making authorities responsible for suicide prevention. 9
General discussion
The majority of our informants were in favour of abolishing the law criminalizing attempted suicide based on the view that suicidal people have mental or other problems they need help with. However, some felt very strongly that the law needs to be kept because it is suicide preventive in that it will deter or scare people from attempting suicide since they fear the law. Implicitly, there is a fear that decriminalizing will lead to increased rates of suicidal behaviour. An important question is then whether such a danger exists. To the best of our knowledge, only one study has looked at this directly: Mäkinen 10 investigated in different ways the effects of decriminalizing suicide in Sweden in 1865. He found that although the rates increased somewhat following the abolishment of the law, this increase had started before the law was removed. Thus, the increase could not be attributed to the decriminalization of suicide.
The situation in Sweden in the 18th century might not be comparable to Uganda in the 21st century. However, consequences of criminalization of suicidal behaviour have been pointed out by the WHO 1 . For instance, refusal to seek help or to give help or treatment to suicidal people due to stigma and/or fear of police investigations and court judgements give reason to assume that decriminalizing may contribute to reduced rates of suicidal behaviour due to increased/improved treatment of suicidal individuals. This is corroborated by researchers in other countries still criminalizing suicidal behaviour. For instance, Vijayakumar in India states that: ‘…the aim of the law to prevent suicide by legal methods has proved to be counterproductive. Emergency care to those who have attempted suicide is denied, as many hospitals and practitioners hesitate to provide the needed treatment for fear of legal difficulties. The actual data on attempted suicides becomes difficult to ascertain as many attempts are described as accidental to avoid entanglement with the police and courts’ (p. 768). 11 Khan 12 takes a similar position with regard to the situation in Pakistan. Also from India, Latha and Geetha 13 emphasize that there is no justification for treating suicidal people as criminals; they should be able to seek help without the fear of being prosecuted. It should be mentioned here that attempted suicide actually was decriminalized in India in 1994 because the Supreme Court found the law criminalizing it cruel and irrational. However, this decision was later set aside for being unconstitutional and attempted suicide was therefore recriminalized in 1996. 13
According to Shneidman, 14 people who are suicidal are in deep distress and are therefore suffering from a more or less transient psychological constriction of affect and intellect; they have a mental ‘tunnel vision’. That is, the range of options usually available to the person's consciousness is not there because in a suicidal state, people tend to see only black and white; either a particular solution or cessation. It is therefore not likely that a person in a suicidal crisis will consider the fact that what they are contemplating is criminal. Besides, one who has decided to kill himself is not likely to be deterred by the possibility of punishment if he should survive. If this is the case, the rationale for punishing suicide attempters is eliminated.
That the majority of our informants were in favour of decriminalizing attempted suicide is good news for the work that the Ugandan Ministry of Health has initiated with regard to getting this law abolished. However, some strongly supported the current law and some were ambivalent. The way professionals view this law is connected to how they view suicidal behaviour and suicidal people. We found that some mental health workers strongly believe that severe punitive actions against suicide attempters will be suicide preventive. Such an attitude among mental health workers frequently encountering suicidal patients raises concern. This indicates a need for educating mental health workers on the consequences of criminalization as well as on understanding of suicidal behaviour/people. We need to increase the awareness in the mental health-care system, and elsewhere in this country, that suicidal behaviour is a result of severe distress and hence a mental health issue, not a punishable criminal offence. Basic training in suicide prevention is also lacking in the relevant educations and should therefore be implemented.
Allegedly, this law criminalizing suicidal behaviour is a remnant from archaic British colonial laws. Britain itself decriminalized suicide in 1961. 15 Most of the countries in the Western world decriminalized suicidal behaviour over 100 years ago, although Ireland did it as late as 1993. 16 We do not know to what extent the law is practiced in Uganda, but we do know that some people are thrown in jail following an attempted suicide. 6 However, according to Ovuga and Boardman 17 who have initiated some suicide prevention efforts in the Adjumani district of Uganda (one of 56 districts in the country), the criminal system in this district no longer prosecutes people for attempting suicide. That is a good start, but in keeping with the views of the WHO referred to above, it is time to not only stop enforcing the law, but also to abolish it altogether.