INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 10: 1077-1084 (1995) SUICIDE IN THE ELDERLY IN ANTIQUITY GEOFFREY SEIDEL Honorary Research Fellow, Wellcome Institute for the History of Medicine, London, UK SUMMARY Self-killing in the elderly of the Greco-Roman world is explored through the study of 89 case descriptions and an investigation of ancient philosophical and medical wri igs. Social, political and ethical dimensions Fe prominent as well as medical and psychiatric ones, and the related issue of euthanasia cannot be avoided. Physical illness and to a lesser extent mental illness were significant caus informed debate on these issues in today's world. KEY WORDS—suicide; history; psychogeriatries INTRODUCTION The rapidly ageing population structure in the western world has led to increasing interest in geriatric medicine and psychiatry and in the sociology and psychology of ageing. An important and challenging aspect of this topic, which will be addressed in this article, is the attitudes and beliefs held about suicide in the elderly and, inevitably, this overlaps with the development of ideas about voluntary euthanasia. Historical and transcultural studies can provide challenging insights and alternative views, The study aims to look at an historical culture which has had a tremendous impact on the western world, namely, the Greco-Roman world of antiquity. Although ancient suicidology has been studied by historians and classical scholars, particul: the German literature, since the late ninete century, very little has been written in the medical or psychiatric literature. In fact, the author could only identify three journal articles touching on ancient suicide in the psychiatric literature. Such a prominent and well-described phenomenon would seem worthy of further research. The researcher could be accused of exploring ancient medical history for purely aesthetic reasons and, while this is partially true, a strong argument can be made for the value, relevance and immediacy of the subject. The Greeks and Romans Address for correspondence. Dz Geoffrey Seidel, Senior Psycho: geriatrician, Downey House, Glenside Hospital, 226 Fullarton Road, Eastwood, South Australia 5063, CCC 0885-6230/95/121077-08 (© 1995 by John Wiley & Sons, Led s of suicide in the elderly. Historical data can contribute towards an developed populous and sophisticated societies where the elite at least had the opportunity to live to an old age. Further, there is evidence that all sorts of writers considered and wrote about the issue of ageing. These include poets, dramatists, historians, philosophers and medical authors. George Minois (1989) states that western culture has found in Greece ‘all the seeds of its success and problems’, while Zeman (1944) points out the continuity of Roman world with the modern age. In pursuing this topic the first prominent source located was the works of Anton L. J. van Hooff (1990, 1993), which cover suicide in general in antiquity. van Hooff has assembled a complete list of references for cases of suicide, parasuicide and suicidal ideation from the ancient literature including history, literature and philosophy and was kind enough to supply the writer with a list of all references pertaining to the elderly van Hoff argues that very few of his identified cases in the general age groups show any link between ‘mental imbalance’ and suicide in the minds of the ancients. In the elderly, he identifies unbearable physical suffering, shame, teadium vitae (disgust with life) and grief as causes, while their most common methods were starvation, cutting and self-poisoning, The aim in this study is to look in depth at the elderly cases from the author's viewpoint as a psychogeriatrician, to try to contrast the findings with current thinking and to attempt to challenge van Hooff’s conclusions. The results have also been viewed in the context of general philo- sophical and medical writings on suicide and mental illness. Received 22 July 1994 Accepted 22 February 1951078 Eighty-nine original references in the ancient literature describing suicide, attempted suicide or suicidal thinking among elderly people were located. The sample of surviving evidence from antiquity is, of course, highly selective, with philosophers and aristocratic figures being far more likely to appear than the general population. Women also tend to be under-represented, with only 13 cased being described. Included together are cases described in fiction, plays and myth- ology. It is justified to consider these as they must in some way reflect the society's underlying beliefs, values and fears, Many of the accounts of historical figures are also written in a colourful and semi-fictional manner to suit the purpose of the author and so it would be artificial to divide the fictional from the real. The author has not used a strict definition of the term ‘elderly’, More often the exact age of death is not mentioned, and so a rough guideline of about 60 years of age or where the term ‘old age’ is used in the text has been employed. The overall place of the elderly in ancient society is clearly a related but complex topic and shows considerable changes over time. Essentially, in both early periods of Greck and Roman history elderly men held great powers politically and within their families. This was particularly so in Rome, where the ‘paterfamilias’ had enormous authority up until the end of the Republic. In both societies the position of the elderly gradually diminished as tradition and institutions changed. In the philosophical literature there is a conflict between the idealization of the elderly by Plato and Cicero and their condemnation by Aristotle. Comic plays derided and satirized elderly men and women although these references diminish in time with the decreased power and authority of the elderly. There was not a well-defined concept of retirement; however, there are references to charitable institutions for the elderly in Greece and there are examples of elderly Romans retiring from public life A more thorough survey of this topic can be found in the work of Minois (1989). GENERAL COMMENTS ABOUT SUICIDE, AND EUTHANASIA It is important to realize that neither Greek nor Latin had specific words for suicide and eutha- G., SEIDEL, nasia, and although each word is derived respec tively from Latin and Greek, they are both composites and inventions of a later age, suicide being the refiexive of to kill (Latin), euthanasia meaning a good or correct death (Greek). The closest word is the late Greek ‘biaiothanatos’, which literally means ‘violent death” but is usually taken to mean to intentionally kill oneself (Cooper, 1989), ‘There is no word for mercy killing. However, Plato in Republic'® supports not treating someone who is incurably ill because even if they were kept alive then they would be unable to lead a full adult life devoted to socially useful employment. It is not clear, however, that this can apply to the elderly as they would not necessarily be expected to perform socially useful employment Turning to the “Hippocratic Oath’ (Interna- tional Hippocratic Foundation, 1960) we read, “I will ... abstain from whatever is deleterious or mischievous. I will give no deadly medicine to anyone if asked, nor suggest any such counsel Looking at some examples involving doctors, we see that Seneca’s physician provided him with poison to assist his suicide. although it failed to work because of his poor circulation, while Hadrian's physician was ordered to give the emperor poison but killed himself to avoid giving it In a review Greek attitudes towards suicide, Garrison (1991) argues that the Grecks recog- nized a sharp distinction between honourable and cowardly suicides and that suicide was often 4 response to social pressures such as desire for honour, fear of shame and self-sacrifice for the good of the whole. In the philosophical litera- ture there is a wide variety of opinions and evidence of considerable debate on the topic of suicide, The Pythagoreans absolutely condemned cide. Their line of thought was that life is a punishment and we should not leave it until the gods are ready. We live in a guard post and should not desert it as this would entail evading the full execution of a just sentence.'* Plato'* described a more flexible ideal. Suicides should be buried in unmarked solitary graves unless under judicial order, excruciating and unavoidable misfortune, or irremediable disgrace he cannot live with Aristotle declares that although there is not @ law against suicide, it is not enjoined by the law, and what the law does not enjoin, it forbids.SUICIDE IN ANTIQUITY ‘Therefore the suicide does wrong, but only against the state, not himself; his suffering is voluntary and no-one wrongs himself voluntarily.* Cicero related the Stoic concept® that if a man sees or possesses in prospect a majority of things contrary to nature, then it is appropriate to depart from life. Seneca quoted the Epicurean view" that, ‘It is absurd to run towards death because you are tired of life, when it is by the manner of your life that you have brought it about ... So great is man’s foolishness, indeed madness, that some are driven to death by the fear of death’. On the other hand Seneca justified suicide for infirmity in old age,” madness,'* senile mental decline** incurable disease,*™ poverty and the tyranny of a despot.'” How- ever, he also added a condition that, even if there are good reasons to suicide, one should abstain if one’s relatives or friends still require one’s services.™ DEATH Beliefs about what happens when we die are important in any discussion about suicide. This subject has been intensively reviewed by Garland (1985). The general Greek belief was that the shades or shadows of the dead occupied an ill- defined subterranean region administered by Hades. The dead were individuals with an image and a soul but without a distinctive intellect, and were unaware of continuing events on earth. They tended to be disagreeable but not malevolent and ideas. of punishment are not common. The possibility of family reunion is mentioned and there is evidence of family burial plots, perhaps to facilitate this, The traditional Roman religion had only a vague notion of life after death (Rose, 1948). The stoic belief that death was final was widespread; a common funerary inscription carried the formula “Twas not; I came to be; I am not; I care not’. The closest idea to heaven is that of Elysion, Burket (1985) comments that this is the abode of the very special few and is in fact to escape death. It is usually described as a distant island with an ideal climate and an easy life. Garland mentions four distinet beliefs about the treatment of a soul after suicide: 1. Regarded as a normal death and treated no differently 1079 2. Rewarded as an act of valour 3. The soul has to wander between the worlds of the living and the dead and is denied entry to Hades 4, Punished in some way There is also evidence of purification rites such as burning the tree on which someone has hanged themselves and cutting off the right hand of the corpse. Traditional Greek and Roman beliefs about death are sharply different to later Christian formulations, which strongly emphasize reward in heaven and punishment in hell, and see suicide as a mortal sin, However, Hudson (1982) argues that Augustine and Aquinas used the writings of Plato and Aristotle to convert suicide from a philosophical consideration to a mortal sin. METHOD In order to derive some meaning and conclusions from the 89 cases, the author has chosen to try to divide them into groups depending on discernible motive. Hudson (1982) has argued strongly against an absolutist approach to categorizing suicide, preferring a neutral stance and an individual approach. Nonetheless, some categorizing is needed if knowledge is to progress and in practice the result reveals a varied and multi-dimensional set of groupings. The categories which have emerged are: 1. Pain/sickness/old age. Cases where the suicidal thoughts of behaviour are closely linked to pain, disease, old age or the general effects of ageing. 2, Military. Cases directly resulting from acute military catastrophe such as the sacking of a 3. Political/social. Suicides resulting from social factors and political conflict including political order to suicide 4, Mental. Any case where words in the text indicating madness, disordered mind or mental decline or incompetence are used in association with suicidal behaviour. 5. Grief/depression/anxiety, Cases where depres- sion, despondency, and emotional responses to adverse events are held to be causative, 6. Unclear/no reason given1080 RESULTS Pain/sickness/old age: 27 cases 1 2. Military: 9 3. Political/socia ses 4. Mental: 9 cases—S mental dectine/incompe- tence, 4 mad/mental disorder 5. Grief/depression/anxiety: 13 cases (44 included under 1, and 1 included under 4) 6, Unelear/No Reason: 9 cases DESCRIPTION 1, Pain|sickness|old age ‘As mentioned above, there appears to have been a fairly widespread acceptance that self-killing was a reasonable solution to incurable illness and in- firmities of old age, although medical euthanasia seems to be excluded by the Hippocratic Oath. The case descriptions show a wide range of conditions which would not be unfamiliar to a modern-day geriatrician and include sensory loss,!* falls,!" inability to care for oneself,'* frailty,” tumours” and possible liver failure."” It must be noted, of course, that ancient medicine was very limited in its ability to cure or palliate chronic disease and to reliably make a prognosis. Senaca states,” “if it (life) begins to resemble a decrepit building then it is time to look about him and consider how he may get out’ Mention must be made of the isolated example of involuntary euthanasia on the island of Keos, where it was customary for the elderly to suicide by poisoning. The exact age limit is not clear but 90 years is mentioned in the moving account of one case by Valerius Maximus” Strabo, however, makes it at age 60.”! In some instances there is clear reference to the ‘cumulative effects of physical illness and psycho- social factors in producing the suicidal event. The link between physical illness and suicidal thoughts with hints of depression and loss in the back- ground gains added interest and relevance when viewed in the context of twentieth-century research, which indicates a definite relationship between physical illness and affective disorder in old age (Kay and Bergman 1966). An argument may be put that itis too simplistic to merely justify these examples of suicidal behaviour on grounds of physical suffering alone because there is evidence of interacting mental and emotional factors as well G. SEIDEL Case vignettes 1. Pomponius Bassalus (funerary inscription.) “but vexed by anxieties of an oppressed mind as well as by numerous ailments of the body so that both were extremely repulsive, 1 appropriated the death I longed for."! Gorgus (sepulchral epigram) ‘Lam already supported only by a stick, like a vine on a stake; death calls me to Hades. What further pleasures hast thou in basking in the sun yet for 3 or 4 more summers? So speaking the old man cast away his life and settled in the abode of the greater number.”? 2. Military These have been considered as a separate category as they describe episodes of acute disaster and distress of a singular nature. The motives for st cide in these cases include avoidance of capture and slavery, fear of the suffering during the sacking of their city and acute grief at the loss of family (usually sons) in battle. Two of the cases are mass suicides of the city elders; these are reported as wise and noble acts rather than the necessary sacrifice of expendable and useless citizens. Case vignette: Old Trinacian men. In 440 ac the Syracusan Greeks were subjugating the Sicillian tives. The only city to hold out was Trinacia. Although they had no allies, the Trinacians held out valiantly and all ended their life heroically. ‘In like manner even the older men removed themselves from life, being unwilling to endure the despite they would suffer at the capture of the city." (Possibly ahistorical) 3. Political/social During the period of the Julio-Claudian emperors there were episodes of large-scale suicides, mainly of senators and prominent people. Most of these were effectively at the order of the emperor in retaliation for real or imagined plots and disloy- alty. The alternative to suicide would have been prosecution, execution and removal of all assets to the emperor. Six of these cases came from this period while three of them date from later emperors and three from the Civil Wars, Other causes include religious persecution, poverty, mistreatment and one case of forced retirement. It could be argued that most of these cases should be considered as executions rather thanSUICIDE IN ANTIQUITY suicide. However, they do strictly belong to this category as they all involve an act accomplished by the victim and there is always an element, however small, of choice. In some cases there is already some suggestion of a willingness to die anyway For example, Xenophon” has Socrates say. “Perhaps God in his kindness is taking my part and securing me the opportunity of ending my life not only in season, but also in the way that is easiest . .. I shall prefer a death to begging for a longer life and thus gaining a life less worthy in exchange for death’. Case vignette: Arruntius. He was an elderly ator during the latter part of the reign of Tiberius. He opened his veins because of disgust with the political situation and fear for his own safety. ‘He had enough of life having . . . endured amid scorn and peril an old age of anxious fears.” 4. Mental As stated above, van Hooff has concluded in his survey of ancient suicide that the ancients did not see a link between mental disorder and suicide. However, my examples in the elderly reveal four cases in which mental disorder or madness. is linked to suicide and five in which mental decline or mental incompetence is mentioned. Not all of the cases are historically accurate; however, the ‘writings prove an awareness that mental disorder could lead to suicide Seneca’s view that suicide was justified for madness and mental decline has already been mentioned. A number of medical authors show a ready awareness of the relationship between age and melancholia, most relating it to middle age and to old age (Willmuth, 1979), The concept of melancholia fits rather uncomfortably into this schema as it overlaps both madness, and depres- sion and grief. There is no doubt, however, that ancient medicine saw it as a physical disorder affecting the brain and as a prime category of madness. Areteus of Cappadocia made an explicit link between melancholia and suicidal ideation: “they complain of life and desire to die’.’ In a passage attributed to Aristotle, but more likely by ‘Theophrastus, there is a rather convoluted sum- mary of the relationship between age, melancholia and suicide; *... if the black bile is unduly cold it produces irrational despondency; hence suicide by hanging occurs most frequently among the young 1081 but sometimes also among older men . .. for old age is a process of cooling...” Thus we can credit this author with the earliest humoral or bi- chemical model of suicide. Despite these abui dant medical writings, only one of the cases (Gaius Marius) resembles classical melancholia ‘Seneca clearly justifies insanity as reasonable grounds for suicide: *.. . and if his sanity should be despaired of, the only remedy is death and if a man probably will never return to his senses, itis best for him to depart’."" The ancient literature lively awareness of the possibility of cognitive decline in the elderly, particularly in comedies, stereotyped old men are often derided (Ri son, 1933). Xenphon has Socrates say, ". if my years are prolonged, I know that the frailties of old age will inevitably be realised . .. that T shall be slower to learn and more forgetful of what I have learnt Areteus’ recognized the distinction between senile mental changes and other mental disorders: "Mania has no resemblance to the dotage of old age, for this is a torpor of the senses and a stupefaction of the intellectual faculties by cold- ness in the system... dotage commencing with old age never intermits, but accompanies the patient until death’. In one of the Sutires, Juvenal'? states: “But worse than all bodily failings is the weakening mind which presently cannot remember names of slaves, nor the face of the friend he dined with last evening, cannot remember the names of offspring begotten and reared! ‘Seneca gives a direct link between senile mental disorder and voluntary death, saying™*:", . . but if ol age begins to shatter my mind and to pull its various faculties to pieces, if it leaves me not life, but only the breath of life, I shall rush out of a house that is crumbling and tottering . . . as long as the illness is not curable’. Both Areteus and Seneca imply that mental decline in the elderly is a disease process rather than an inevitable part of ageing In the five cases identified, the suicidal thoughts or behaviour are generally linked to derision and shame at an example of mental incompetence, for example in a story about the aged philosopher Diodorus Cronus, who was unable to solve a dialectic question put to him by Stilpo.'®* Current research in psychogeriatrics shows a variable but definite proportion of cognitive decline in elderly suicide attempts (Kay and Bergman, 1966), also shows a1082 Case vignetie: Gaius Marius. Gaius Marius was a prominent leader in the late Roman Republican. period and had a brilliant military career but was aan inept domestic politician, He was still in power in old age but Plutarch described his as ‘given to hesitation and delay . .. old age had quenched his energy and desire . . . his nerves were diseased and his body unfit for work’. Later he is described as afloat on a sea of anxiety . .. his spirits sank and he could not raise them... he fell into a terrible state of despair, he feared sleepless nights and indulged in bouts of drunkenness. He heard voices and developed wild delusions’, Plutarch'”* has him dying of natural causes, but Diodorus” describes him as ‘departing from life of his own volition’. (Uncertain historical accuracy) 5. Depression)griefjanxiety This group of cases show a link between what we call ‘stressful life events’ and suicide. For the most part they consist of acute or chronic bereavement and grief at the loss of a close relative, particularly oflspring: however, three cases involve shame at the conduct of younger people associated with them. Finally, two of the cases appear to be chronically anxious people affected by adverse circumstances. Vogel and Wolfersdorf (1989) emphasize the role of age-related stresses sich as bereavement and loneliness in ‘current western society. Case vignette: Aegeus. When Theseus, prince of Athens, was sailing home from Crete having slain the Minotaur he forgot to hoist the bright sail which was to have been his token of safety. On seeing the dark sail approaching, his father ‘Aegeus, in despair, threw himself from the rock and was dashed into pieces.'”® (Semi-mythological) Not al of the cases are so sudden and impulsive, some involving long periods of grieving and a string of multiple losses. Unelear|no reason Several suicides in elderly men are reported with no particular reason given. Three of these are in Lucian’s Octogenarians and it is curious that he should mention their age and mode of death without any reason being given, although it may be reasonable to assume that the infirmities of age might have been involved. The existence of this group lends support to van Hooff’s notion that the G.sEIDEL ancients had a superficial way of exp: (van Hooff, 1993), ing suicide DISCUSSION Although the author has drawn on a wide range of sources including philosophy, tragedy, comedy, history, religion, mythology and medical writings, the aim of the study has been biased towards finding a medical model of suicide and in this there has been a degree of success. The way in which the cases have been grouped is preconceived to be sensitive to picking up cases which fit into a medical/psychiatric model. Taken together, the categories of physical illness, mental disturbance and mood alteration make up 49 of the total 89 cases. ‘The most populous group are those with pain, chronic physical illness and general frailty of ageing, and there appears to be a consensus between most philosophical schools that this is a just reason to kill oneself. While the Hippocratic Oath forbids any sort of iatrogenic deliberate Killing, the very need for such a proscription suggests that it must have been happening. In fact, in a review of the Hippocratic Oath, Edelstein (1967) argues strongly that Hippocratic physicians commonly assisted the death of Patients with incurable disease and suffering and suggests a Pythagorean influence in the wording Several case descriptions show an awareness of the combined effects of psychological distress, depression and physical debility and it is instruc~ tive to compare this with recent research which indicates a definite relationship between physical disorder and depression in the elderly. Only the case of Hadrian shows a physician acting to prevent a suicide and this ends in the suicide of the physician himself. It cannot be denied that there is a significant body of evidence both from the descriptions and from more general writings that mental disorder was seen as. a potential cause of suicide in the elderly. While the cases are few in number and are either fictional or of doubtful accuracy, the existence of the writings indicates a belief that ‘madness or mental decline in the elderly might be a sufficient reason to suicide. Some philosophers and the later Greco-Roman medical writers, on the other hand, show quite @ definite awareness of mental disease in the elderly and its possible relationship to suicide. This is of particular interestSUICIDE IN ANTIQUITY as it is a central precept of modern conventional clinical psychiatry that mental illness be first excluded in any case of attempted suicide. While grief, depression and anxiety are normal emotions, psychiatry today dictates that beyond a certain severity they become pathological and deserve the attention of the medical profession. The ancient sources certainly see the relationship between this sort of acute or chronic mental distress and suicide but tend to portray it as natural, inevitable and even honourable rather than as a sign of mental imbalance or loss of reason. In terms of psychological dynamics, shame at one’s own conduct or loss of face, or at the conduct of close relatives is often the driving fore One should however, note that Hippocratic writings accept that unpleasant and. distressing events and prolonged fear can also lead to melancholia (Roceatagliata, 1986). The remainder of the cases have been attributed to military, social and political phenomena. To a large extent the pattern and manner of these suicides depended on the particular forms of social and political organization and the more personal and close-at-hand nature of battles at that time Durkheim's social theories of suicide are well known and he considered the rate of suicide in a society as a measure of the health of the social body (Durkheim, 1897). The rash of suicides in the senatorial classes during the imperial period certainly occurred during a phase of extreme social flux in which traditional ideas of identity, roles and power were ambiguous and constantly changing. Comparison can be made with recent psychoger- iatric research (Kay and Bergman, 1966; Pritch- rd, 1992; Vogel and Wolfesdorf, 1989), which is fairly unaminous in finding that mental disorder alone is insufficient 10 explain the suicide rate in the elderly but that social variables such as isolation, retirement and socioeconomic changes are also involved, The abuse of drugs and alcohol is recognized today as a standard risk factor for suicide. However, none of these cases make this a prime cause although it is mentioned as a. background factor in four. Drinking unmixed wine is some- times mentioned as a method of suicide and it is generally believed that there was a very high alcohol content in the wine in ancient times. ‘As might be expected, no single model can explain the phenomenon of elderly suicides in antiquity. Medical, psychiatric and emotional disorders appear in many cases; however, others 1083 result from environmental, social and_ political conditions with impulsive and superficial beha- viour appearing in some. It is also fair to conclude that the Stoic view, as most clearly and thoroughly expounded by Seneca, offers the most comprehei sive explanation of the recorded cases of geriatti suicide in the Greco-Roman world: that is, strong condemnation of cowardly or unnecessary suicide but a qualified acceptance in cases of incurable mental and physical disease, senile mental decline, poverty and political tyranny Seneca was also called upon to put his beliefs into practice on the order of his former pupil Nero and so perhaps he should have the Jast word, those given him in Monteverdi's opera “L” incoronazione di Poppea’ Friends, the hour has come To put into practice That virtue I have so often praised. 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