1. Introduction

Suicidal behavior and in particular self-inflicted death has increased in several countries of the world; Mexico has not been the exception. According to the World Health Organization ⁽¹, ²⁾ every year about 800 thousand people commit suicide, which is equivalent to the self-inflicted death of one person every 40 seconds ⁽³⁾, however, there is concern about an increase in the numbers associated with the challenges and adversities that have been faced in recent times in the health, economic and social areas.

Self-induced death is multifactorial; its etiology is linked to mental disorders, personality disorders, acute life crises, profound unhappiness, loss of meaning in life and absence of a life project. However, it is important to consider also the influence of elements that add to critical conditions and constitute risk factors, such as exposure to mass media contents that promote violence and that, particularly in relation to suicidal behavior, do not follow the ethical guidelines of the World Health Organization. This article will write about what has been called the «contagion effect» of suicide and, therefore, the link between suicidal behavior and mass media, as well as the bioethical implications that intertwine both issues.

2. Mass media and exposure to violence

The mass media have a significant influence on the development of culture ⁽⁴⁾; when media content is violent, the mental impact on people, especially children and adolescents, is significant ⁽⁵⁾, and can even generate social isolation, destructive behavior, cyberludopathy, media addiction, mental health problems, antisocial behavioral disorders, and desensitization to violence, among others ⁽⁶-¹²⁾. However, there is also evidence of the adverse impact of violent news on all types of people, regardless of age, gender and culture, since the media content they are exposed to influences their perception of violence ⁽¹³, ¹⁴⁾.

Therefore, it is essential for parents to monitor the media content that their children or adolescents watch or listen to, as this will have a protective effect on their physical, emotional, academic and social development ⁽¹⁵⁾. Likewise, it is important to develop media strategies against violence in order to reduce it ⁽¹⁶, ¹⁷⁾.

3. The media and the «contagion effect» on suicide

On the subject of suicide, the «contagion effect» that can be produced by the media has been studied. The media play a transcendental role in the current life of the population, particularly adolescents, who consider technology and the use of social networks to be a fundamental part of their lives ⁽¹⁸⁾.

The first allusion to the phenomenon of suicide contagion is made with the so-called «Werther Effect», so called because after the publication of the book The Sorrows of Young Werther by Johann Wolfgang von Goethe (published in 1774 and in which the protagonist commits suicide), an increase in suicides of young people in circumstances and clothing similar to that of the protagonist of the novel was observed. The sociologist David P. Phillips would investigate this phenomenon after observing the increase in suicides after a suicide story was published in U.S. newspapers, particularly in the New York Times. His research concluded that media coverage of suicide increased the suicide rate in the population where such coverage took place ⁽¹⁹, ²⁰⁾; other authors ⁽²¹⁾ corroborated this by identifying that adolescent suicide in the United States from 1988 to 1996 occurred in clusters, and not just in isolation, when newspapers reported suicides on the front page, described the method of suicide, and placed headlines with the word «suicide. In contrast, for example, in Vienna, it was found that when media reporting of suicide notes in the subway was shorter and less dramatic, suicides and subsequent suicide attempts decreased considerably ⁽²²⁾.

Japan is one of the countries that has most studied whether media coverage of suicide influences the repetition of suicidal behavior.¹ They have concluded that images of suicide have an important influence on psychologically vulnerable people to attempt suicide, even using methods that are unusual for the culture ⁽²³⁾. In the same country, research on the impact of the diffusion of suicide through newspapers indicates that if the news about suicide or attempted suicide is placed on the front page, it has a four times greater impact on people than if it is placed elsewhere in the newspaper. This impact increases if the time of exposure to the news increases, which in Japan is 1-3 days (i.e., the news about a completed or attempted suicide is exposed on average one to three days in newspapers). If the media do not follow the recommendations that have been made in that country and internationally on the dissemination of suicide, the contagion or copy-cat effect increases significantly ⁽²⁴⁾.

In China, the contagion effect has been studied by analyzing the spread of the suicide method, which can transcend borders, as was the case between 1998 and 2005 with high jumping (as a means of suicide), which spread to Taiwan, Japan, Korea and Singapore. However, these investigations focus not only on the imprint of the media’s dissemination of the suicide method on the population, but also on the motivations for suicide, such as divorce or financial crises, which are a risk factor for suicidal behavior in China and the world. The incidence of the contagion effect is higher in urban areas than in rural areas ⁽²⁵⁾.

In Western culture, evidence of the contagion effect of suicide and its relationship to the media has also been found. An example of this was the book Final Exit, which offered a guide to suicide for the terminally ill; the method it suggested was asphyxiation. During the year of publication of this book (1991), suicides by this method increased by 313% in New York City, with a copy of this book being found at the place of death in 27% of the suicides ⁽²⁶⁾.

Another example is the American television series «13 Reasons Why» which shows the suicide of a young woman and the apparent motivations that led her to commit this act. A research conducted in the United States noted that from the premiere of the series on March 31, 2017 until April 18 of the same year, an increase in internet searches related to suicide was observed. On 12 of the 19 days studied, queries about suicide were significantly higher, ranging from 15 (as of April 15, 2017) to 44 percent (as of April 18, 2017). The increase in specific searches on «how to commit suicide» was 26 percent, «commit suicide» 18 percent, and «how to kill yourself» 9 percent. Internet queries about suicide prevention and hotlines for help also increased («teen suicide» increased 34%, «suicide prevention» 23%, «suicide hotline numbers» or «suicide hotline number» 21%, and «suicide hotlines» or «suicide hotline» 12%) ⁽²⁷⁾. One study identified that the suicide rate in young males aged 10 to 17 years in the United States rose 28.9% in the month following the premiere of the first season of this television series and remained elevated for the subsequent two months^{2 (28)}.

The «contagion effect» is evidenced in a 2018 Canadian research establishing the association between harmful and protective factors of media reports of suicide. It has been identified that some of the elements that increase suicide in the week following the publication of a suicide or attempted suicide story are: assertion that suicide was inevitable (1.97 times), placing the suicidal method in the headline (1. 41 times), if the suicide method is hanging or asphyxiation (1.72 times), if the method is jumping off a building (1.7 times), talking about a suicide pact (1.63 times), if the suicide method is by firearm (1.3 times), if the suicide is by a famous person (1.3 times), and if the suicide is by an older adult (1.25 times) ⁽²⁹⁾.

On the contrary, protective factors for suicide are: public policies to prevent suicide, pointing out the unfavorable personality characteristics of the deceased, whether the method of suicide was by throwing oneself on the train tracks or by cutting or stabbing, or whether it was a person who was first homicidal and then suicidal ⁽²⁹⁾.

4. Factors that increase the «contagion effect» of suicide

The contagion effect of suicide is based on the association between the following elements ⁽³⁰⁾: (a) one behavior and another by mass contagions related in time that overcome geographical barriers and that have in common the news disseminated about the suicide of a celebrity (mass clusters); (b) by point or related contagions in space-time (point/space-time clusters) -for example, those occurring in prisons, institutions, hospitals or schools- or those occurring by imitation of a suicide (echo cluster), generally associated with the media coverage of the same.

The influence of suicide exposed in the media seems to be greater when the news is about a famous person, since the coverage is repetitive for days and more specific about the circumstances surrounding the suicide, the apparent motive and the method itself ⁽³¹-³³⁾. But it also has a greater effect because people create para-social relationships with celebrities; that is, even if the public does not know the celebrity personally, they establish an affective relationship with the celebrity, identify with him or her and even feel they know him or her ⁽³⁴⁾. The impact increases if the celebrity and the public are of the same nationality (increases the degree of personal identification) and if there is a suicidogenic environment in the population (e.g., adverse living conditions) ⁽³⁵⁾.

In some cases, the media sensationalize the news about the suicide of a celebrity with inappropriate language; they imply that suicide was the logical way to go and do not mention the probable mental disorders underlying the suicide. Most of the time the news is accompanied by images of the death or the deceased body ⁽³⁶⁾, which, together with what has already been mentioned, increases up to 14 times the possibility of the «contagion effect» on suicide ⁽³⁷⁾. This is concentrated in the two weeks following coverage of the celebrity’s death, but can continue for up to four weeks afterwards. In contrast, if the media do not openly disseminate the news about the suicide, the «contagion effect» remains for only one week ⁽³⁸⁾.

An example of how publicizing the suicide of a famous person can increase the suicide rate is Korea. Researchers ⁽³²⁾ systematically reviewed the news about the suicide of a famous Korean singer,³ the prevalence of suicide attempts or completed suicides, and the motivations for suicide attempts with direct interviews of the suicide attempters, and concluded that the rate of suicide attempts and completed suicides increases in the four weeks following the dissemination of news about the suicide of a famous person, and that the rate is related to the behavioral imitation effect, the identification of the famous person by age, the associated motivation, and the method used.⁴

On the other hand, the use of the Internet and social networks can be a means for suicide prevention or its promotion; adolescents and young adults can be highly influenced by the pro-suicide content presented in some social networks, which is easily found in Internet searches ⁽³⁹⁾. There are even specific sites that explicitly induce suicide, and others that do not do so openly in the title, but have content (verbal, in images, videos, movies or music bands) that is suicide-oriented ⁽⁴⁰⁾.

In sum, it has been found that the media influence the repetition of suicidal behavior, since the news coverage in newspapers, television and the Internet focuses on showing the details of the suicide method but does not responsibly expose the causes of self-induced death. Generally, they attribute the suicidal act to a crisis or personal failures, but do not indicate the complexity of suicidal behavior, the underlying mental disorders that may exist and the vulnerability that some people may present ⁽⁴¹, ⁴²⁾.

In this perspective, it is recommended to be careful with the way in which suicide notes are disseminated ⁽⁴³-⁴⁵⁾. It is essential that the media be guided by ethical guidelines that promote truthful information and mental health, as well as minimize the harm that its content can generate, both to the protagonists of a note, as well as to the general public ⁽⁴, ⁴⁶, ⁴⁷⁾; the media should transmit information according to the guidelines of the World Health Organization ⁽⁴⁸-⁵⁰⁾.

5. Protective effect of the media on suicidal behavior

Responsible media coverage of suicide may have a preventive effect on the development of violence and suicidal behavior ⁽⁵¹⁾.

This effect, known as the «Papageno effect»,⁵ consists of showing the public that there are more effective and positive ways of dealing with emotional crises without the need to resort to suicidal behavior ⁽⁵²⁾; It can have favorable consequences when the relatives of the person who has committed suicide are interviewed by the media in an ethical manner, with the purpose of avoiding future suicidal behavior ⁽⁵³⁾, when the media help to reduce the stigma and stereotypes about mental disorders ⁽⁵⁴⁾, and when they disseminate information about the recovery that can be achieved by people who have attempted suicide and who have received timely medical and psychological care ⁽⁵⁵⁾.

As mentioned above, the World Health Organization, the Pan American Health Organization, and the United Nations Children’s Fund have issued recommendations to the media on how to convey stories about suicidal behavior ⁽¹⁹, ⁴⁸, ⁵⁶-⁵⁹⁾, and have provided guidelines to filmmakers on how to ethically handle this topic in movies and television series.⁶ Some of the recommendations made are:

It is also suggested not to mention the name or characteristics of the person who committed suicide, not to make references to Internet forums on suicide, suicide pacts or places where a greater number of suicides are located (they trigger risk points); mentioning suicides that are close in time or space should be avoided, and, on the contrary, prevention factors should be highlighted, which are scarcely placed in the notes on self-induced death ⁽⁶⁰⁾.

Likewise, it is recommended to provide information on care centers where a person with suicidal ideation can seek help, to highlight the favorable alternatives that exist in the face of crises, to disseminate risk indicators and warning signs for suicide, and to send messages of solidarity to suicide survivors ⁽⁶¹⁾.

These recommendations also apply to the internet platforms and social networks that young people use, as some consult them as a form of socialization or in search of information, but others (in the case of those emotionally vulnerable or with a mental disorder), approach them for support ⁽⁶²⁾.

A sign of the lack of follow-up to the recommendations of the World Health Organization was the treatment given to the suicides in 2018 of two famous people: designer Kate Spade and Chef Anthony Bourdain. In both cases, the stories of their suicides were reported by media outlets around the world and replicated several weeks after the events.

In the case of Kate Spade,⁷ images and videos were shown of the police removing the body from the designer’s house, the suicide note that was found next to her body, statements from Spade’s sister and husband were shown, and they detailed how the designer committed suicide, what method she used and even how and by whom her body was found. Some media mentioned interviews indicating that Kate had been suffering from depression and anxiety for more than 5 years for which she initially received treatment; apparently the treatment was later abandoned due to a probable fear that her brand would be damaged ⁽⁶³, ⁶⁴⁾. Only a few media outlets included in their stories a link to get help for suicidal ideation.

The dissemination of the designer’s suicide gave rise to multiple reactions from social network users, some commenting on how difficult it is to suffer from mental illness and how complicated it is to survive the suicide of a family member; others criticized the decision to commit suicide and others, on the contrary, said that Kate’s suicide was a good decision, since in this way she would be saving her company.

The suicide of the famous Chef Anthony Bourdain⁸ occurred on June 8, 2018 by hanging in the hotel Le Chambard in Kaysersberg, France, was also a news reported by media around the world. On radio, television, internet and social networks, Bourdain’s death and the information derived from it was reported for more than a month. Some media were explicit in indicating that the chef died by hanging and detailing the method used. Other news reports alluded to Bourdain’s chronic depression and the addictions he had struggled with in the past. They even emphasized statements the chef had made in 2017 where he expressed the regret he felt regarding the harm these addictions had caused to others. Only some media alluded to probable triggering events about suicide, such as depression, personal and economic crisis ⁽⁶⁶⁾.

As has been mentioned elsewhere in this document, that the media follow the recommendations of the World Health Organization and disseminate news about suicide in an ethical and responsible manner, helps to inform the population responsibly about mental illnesses with the consequent decrease in the social stigma of mental illness, to prevent suicidal behavior and to reduce the interpersonal risk factors that especially affect young people ⁽⁶⁷, ⁶⁸⁾.

6. Bioethical implications of the «contagion effect» of suicide

The «contagion effect» of suicide should be analyzed not only from the areas of mental health and communication, but also from a bioethical perspective, since it should be based on the premise that there are several risk factors for suicide, including vulnerability. This is a principle proposed in the Barcelona Declaration of 1998; it is an anthropological dimension that refers to the fragility and susceptibility to harm associated with the human condition itself ⁽⁶⁹⁾. However, there is also social vulnerability, a marker of disadvantage, which refers to marginalized population groups that have limited access to the satisfaction of their basic needs and health care.

Although it is true that being vulnerable is not the same as having been vulnerable, it should be recognized that people with suicidal behavior have generally been vulnerable and that they also present social vulnerability, this concept being understood as anthropological vulnerability intensified by socio-environmental factors that place a person or group in a state of defenselessness, and that may be a consequence of living in conditions resulting from marked social disadvantage ⁽⁷⁰, ⁷¹⁾. In the case of people with psychiatric or psychological conditions, or with life crises, the difficulty in accessing health services is undoubtedly a disadvantage that places them in social vulnerability. Emotional disturbance itself, confusion and existential doubt, as well as probably the lack of a social support network, interfere with the way in which messages received from the outside, such as those expressed in the media, are interpreted.

In this regard, adherence to the ethical guidelines of the World Health Organization on suicide stories in the media should be considered. One of the bioethical recommendations would be to provide clear guidelines and training to the media on the transmission of news related to suicide. Other recommendations are to promote orientation towards the universal truth and good, to favor -through the family and society- the consolidation of a solid identity, and to encourage the formation of affective bonds between people so that they can form a community and feel an effective part of it.

Suicide also operates against the principle of sociability-subsidiarity that commits the members of a community to collaborate in obtaining the good of all, especially if this good refers to the promotion of life and the maintenance or procurement of health ⁽⁷²⁾. Therefore, when someone in the community is lost, the community should ask itself what it did to cause that person to commit suicide and what it should do to prevent suicide.

This would involve the analysis of the «contagion effect» of suicide by imitation and impact of knowing the suicide note of another person and identifying in some aspects with this person. Also, consider the suffering of the relatives of a suicidal person, which translates into complicated grief, development of physical and mental illnesses and suicide attempts themselves ⁽⁷³, ⁷⁴⁾, so that the unfavorable impact of the «contagion effect» of suicide affects not only the person who performs the act, but also his or her family and other members of society.

The bioethical analysis should also consider subsidiarity, which not only involves respect for the good that someone can procure for himself or someone else can procure for someone else, but also solidarity in supporting those who cannot help themselves or who are not in a position to seek the help they require ⁽⁷⁵⁾. This would be the case of a person who is hopeless, with a diminished sense of life, existential emptiness and/or emotional crisis, and of those who suffer from a mental and/or personality disorder. By subsidiarity, help should be provided to those who cannot reach it on their own, but also to those who are most in need.

Finally, to emphasize the respect that must prevail for the dignity and integrity of human persons, as well as the search for the construction of a more empathetic and supportive society, promoter of the common good.

7. Conclusions

Suicide is a public health problem that has increased significantly in Mexico and the world; given its multifactorial origin, it is important to understand the risk and protective factors associated with it. Within the risk factors, the analysis of the «contagion effect» of suicide as an element of unfavorable influence for people with social vulnerability, such as those who generally suffer from a mental disorder, or who are going through confusion, hopelessness or life crisis, is of particular significance. Suicide operates against sociability and subsidiarity, breaks the social fabric and affects the community, therefore, it is essential to adhere to the ethical guidelines of the World Health Organization regarding self-induced death, as well as the promotion of respect for the dignity and integrity of the human person.