Suicidal Behavior in Mexico: Legal and Bioethical Perspective

Introduction

Worldwide, it is estimated that every year, one in 100 people take their own lives after numerous suicide attempts ¹ , which translates into a public health problem that directly affects mental health and the quality of life of people around the world. The World Health Organization (WHO) defines Mental Health as a state of well-being in which all individuals develop their potential, can cope with the stresses of life, can work productively and fruitfully, and can contribute something to their community. ²

After the COVID-19 contingency, worldwide there was an exacerbation of suicidal behavior, in Mexico this trend continued, however, statistical reports show an alarming phenomenon in the age group of adolescents, an increase in the incidence of suicide attempts that did not previously manifest suicidal ideation, which may predict higher rates of suicides ahead ³ , for this reason, the Ministry of Health, in collaboration with governmental agencies, has presented work agendas to reduce mortality caused by suicide through prevention, care, education and research on mental health. The main point of the legislation on suicide in Mexico is prevention, also contemplated is the support of patients and their families, however within our health system we do not have the infrastructure to provide quality mental health care, so patients have to pay for this expense, which makes it inaccessible and in situations of despair or suffering that patients themselves refer to as unbearable, patients see suicide as the only way to escape. ⁴ -7 The main approach provided to patients is palliative therapy; however, in some cases there is a failure to control discomfort or suffering, so some countries have legalized methods of aid in dying such as euthanasia or medically assisted suicide, a controversial decision, some bioethics societies have said that the value that can be given to death is directly proportional to that given to life, on the other hand, there are those who indicate that scientific and technological development allows us to use new therapeutics and that it is imperative to give the most humane treatment until the end of life and to avoid any suffering. ^{8 , 9 , 10}

METHODOLOGY

The research into information on suicide and the legal punishment of suicidal behavior was conducted in legal documents such as international agreements, the Constitution of the United Mexican States, the General Health Law, the Federal Criminal Code, the Mental Health and Suicide Prevention Law for the State of Hidalgo and a state-approved website. At the same time, information was sought in online portals of organizations such as the United Nations Children's Fund (UNICEF), the United Nations Educational, Scientific and Cultural Organization (UNESCO), the World Health Organization (WHO), the Pan American Health Organization (PAHO) and the most important bioethical societies to learn about their positions on suicidal behavior and medical assistance in dying.

The descriptors used were: suicide, suicide prevention laws, medically assisted suicide, euthanasia, criminalization of healthcare providers, autonomy, justice, beneficence and nonmaleficence. The search chain for the research was established as follows: the topic of legal framework and bioethical positions on suicide was selected; subsequently, the search was divided in order to find the most complete overview of the current law in Mexico; in a second stage, the ethical principles and positionings coined by some bioethical societies were investigated.

DESCRIPTION AND ANALYSIS OF RESULTS

Data on Suicide Conduct

The preliminary INEGI survey of 2023 showed 8,837 deaths by suicide, which represents 1.1% of the total causes of death, highlighting a more significant prevalence in the male sex with 81.1%, with a predominance in the population under 40 years of age with 65%, and showing that the most used methods are those that produce hanging, suffocation or strangulation with 85.5% and this occurs most frequently in the family domicile. The states with the highest suicide rates were: Chihuahua, Yucatán, Campeche and Aguascalientes; the state of Hidalgo was ranked 19th in this survey. ¹¹

The results of the National Health and Nutrition Surveys (ENSANUT) of 2022 showed that suicidal behavior is a public health problem, adolescents make more suicide attempts, as shown by the rate of suicide attempts in adolescents of 5.3% compared to adults which was 3.5%, the latter showed a greater tendency to present suicidal ideation, however suicide attempts are able to predict subsequent attempts, in addition to these occur with greater frequency and lethality, which is the essential reason for protect children and adolescents. ³

The rate of psychotherapeutic interventions reported in 2024 by the General Directorate of Health Information reported that 332 people requested support for suicidal ideation and 329 for suicide attempts, with a prevailing number of female patients, and Nuevo León was the entity that reported the highest demand for attention. ⁴

Legal Framework of Suicide

Mexican legislation does not criminalize attempted suicide or suicide, in view of the fundamental principle being to protect the right to life, so laws have been created to promote actions to prevent suicidal behavior and attend to postvention, through the training of personnel providing mental health care, education to all sectors of the population and assistance for both the patients and their social network. ¹²

Mexico is a party to international conventions whose imperative is to safeguard respect for fundamental rights, and the right to health is a cornerstone. The article 25 of the International Declaration of Human Rights states that every person, without distinction of any kind, has the right to enjoy an adequate standard of living, in which quality medical care is provided. ¹³ The International Covenant on Economic, Social and Cultural Rights explicitly recognizes that mental health is a key factor in the free development of the personality and the enjoyment of the highest achievable level of health. ¹⁴ The United Nations Sustainable Development Program in the fourth target of goal 3 indicates that mental health care is necessary for a good level of well-being. ⁷

The Political Constitution of the United Mexican States guarantees the protection of the right to health through its fourth article ⁵ and in turn, the regulation of this right is established in the General Health Law, which recognizes the right to Mental Health in the reform of 2022, considering which the State is responsible for securing universal access, equal and equitable attention to mental health care and addictions to people in the national territory, through actions of promotion, prevention, treatment, recovery and protection of human rights, while seeking to eliminate discrimination and stigmatization of mental disorders. The General Health Law through 6 articles stipulates that: mental health is a fundamental right necessary to achieve a complete level of wellbeing; the Ministry of Health, the state health systems and the corresponding authorities are the entities responsible for ensuring that mental health actions are carried out; It also establishes that the mental health staff responsible have rights to be trained for such purposes; patients have the right to receive comprehensive, respectful care and to have a written diagnosis and treatment plan; if necessary, to receive duly informed consent and medical counseling for vital decision-making purposes or to exercise pre-arranged desires, which are meant to regulate orthothanasia; another objective is to regulate hospitalization in order to provide care with an ethical perspective and, finally, to strengthen the social network by providing care to family members and members of the social network who could be affected. ⁵ , 6

A little more than half of the states in Mexico have mental health laws, but only three of them have laws focused on suicide prevention: Coahuila, Sonora and Hidalgo, the last one published in 2024, whose emphasis corresponds to the investigation of psychiatric emergency cases, their care and epidemiological updates. ⁷

For the purpose of implementing mechanisms to intervene in suicidal behavior and reduce mortality, programs such as the National Suicide Prevention Program and the National Suicide Prevention Campaign “Dale color a tu vida” have been created, the latter being a collaborative strategy between the National Commission on Mental Health and Addictions (CONAMASA, for its acronym in Spanish) and the Ministry of Health, which offers an educational approach to raise awareness and prevent suicide. ¹⁴

Despite the strategies that have been implemented, there are still conditioning factors of health that are important to analyze because they facilitate the evaluation of inequalities, factors that limit the development of a population's well-being, ¹⁵ , 16 for example, the cost of health care services caused 381 million people (4.9% of the population) to fall into extreme poverty. ⁸ The Official Human Development of the United Nations Report and the Oxford Human Development and Poverty Initiative estimated a multidimensional poverty index to assess the level of deprivation in 3 primary dimensions of life: education, health and quality of life, assessing that out of 6.1 billion people in 100 cities, 1 .1 billion live in extreme poverty, and between 824-991 million does not have access to health care. ⁹ When viewed in the context of inequality and inaccessibility to basic health services, a large part of the population perceives death as the only solution. ¹³

Countries such as the Netherlands, Colombia, the United States, Australia, Belgium, Luxembourg, Spain, Canada and New Zealand have proposed alternatives to deal with unbearable suffering through medical assistance in dying such as: euthanasia, the act in which a physician employs some method to bring about death, or medically assisted suicide, in which the physician issues a prescription for a drug that causes death. ^{10 , 12} Both practices are heavily questioned, under the principle of attacking a fundamental right, life. At the same time, another question arises as to whether the legalization of medically assisted death will put these countries in a classification of “destinations for dying” that would allow pro-euthanasia tourism, but the reality is that there is an almost bureaucratic control. The requirements that have to be met are strict, for example: patients need to stay for pre-established times in the territory where the end of life is to be carried out; it is expressly requested that the patients be of legal adulthood, if they are patients who have not yet reached the age of majority, the regulation is only permissive in cases of terminal illnesses and it is necessary to prove that the infant has an adequate level of neurocognitive maturity; in the majority of countries that have legalized euthanasia, it is only applied in untreatable chronic pathological conditions or terminal phases of the disease; the first evaluation must be performed by a physician, who is in charge of reporting on the physical condition, the level of suffering, the degree of autonomy and to corroborate that the patients have the capacity to make their own decisions in a well-reasoned way; It is then submitted to a committee composed of a jurist, a physician, a bioethicist and, in some cases, a psychiatric or psychological evaluation is requested; if the corresponding committee is not available, the evaluation of a second physician is demanded, so that a double but independent medical evaluation is possible in order to reach a consensus; the next step is to sign the informed consent form, in which the patients autonomously expresses their decision. In the majority of countries, files are made anonymously, however, if the corresponding authority finds inconsistencies in the case, it may request that the case be reviewed. Therefore, at the end of the day, the choice to perform a medical assistance in dying procedure is a slow process, which goes through several stages of evaluation, with what is understood to be a premeditated process, in which through different points of view a resolution is reachedIt is important to emphasize that firstly, a life support treatment or palliative accompaniment focused on the particular case is proposed, and secondly, in a lot of cases of mental disorders, the procedure is rejected because the discomfort presented by the patient is not considered objectively evaluable. ¹⁰ , ^{17 , 18}

In the nation of Mexico, there is yet no legislation that allows medically assisted death, so it is classified as a crime of homicide and punishable by a prison sentence, as stipulated in Article 312 of the Federal Criminal Code, which states that anyone who assists or induces another to commit suicide shall be punished with one to five years in prison; if he assists to the point of executing the death himself, the prison term shall be four to twelve years. Article 313 of the same legal ordinance advocates for minors and for people who have a condition that limits them to make their own decisions in a conscious way. Therefore, there are three ways of participation provided by law: a) moral participation of inducement; b) material participation of aiding and abetting; and c) material participation, consisting of the one executing the death, that is, the homicide with the consent of the victim. ¹²

In Mexico, the possibility of choosing to end one's own life is far away, and the only resource available to patients with pathological entities in terminal phases is intensive life support accompanied by palliative care, with the freedom to decline to receive them by signing an informed consent or to leave their medical decisions pre-established in a pre-arranged voluntary directives document. ^{5 , 6}

Bioethical Positions Around the World

Medical assistance in dying is a controversial issue that from a bioethical point of view, the medical act has been governed by values whose principle is to preserve life and the care implicit in it, so that supporting positions such as assisted suicide could be considered a practice that violates a fundamental right. By the other hand, work on scientific discoveries and technological advances are published at dizzying rates; this knowledge can be applied in therapeutics, but it is important to regulate them, for that reason the ethical-legal implications need to be studied in parallel to prevent the polarization of early choices and finally to establish a debate forum in which the biopsychosocial context is always taken into account. ¹⁹

The positions that bioethics societies have adopted regarding suicidal behavior are based on the four fundamental principles: nonmaleficence, beneficence, autonomy, and justice. The exercise that represents autonomy is consent, since the patient can freely chooses a decision after being provided with information, on the other side, the principles of beneficence and non-maleficence characterize medical treatment, whose main objective is to help the patient by offering the best treatment, and finally, the principle of justice conceptualizes that all patients have the right to have the proper medical care, in proportion to the condition that afflicts them. ²⁰ Aside from basing their positions on fundamental principles, the thought reflects in a considerable way the ideology of the members of the societies, so that we can have more conservative or liberal positions. ²¹

The World Medical Association recognizes that adolescent suicide is a global health problem, whose biopsychosocial background limits the approach, mentioning that the economic factor has a considerable influence, for which reason preventive efforts must be made ²² and in the presence of suicidal behavior, it exhorts physicians to conduct a deep investigation of the event in order to know the motives behind it; in opposition, it condemns medical participation in assisted death, a practice that has only been contemplated in the context of terminal patients, for whom they advocate for laws and regulations to promote intensive life support treatments and comprehensive palliative care. ²³

From the standpoint of the Steering Committee on Bioethics of the Council of Europe, an intergovernmental body of 47 member states is not expressing a judgment about suicide but has made a statement against assisted dying practices, highlighting that legalizing practices such as euthanasia or assisted suicide is an attack on human dignity and the right to life, and that if medical intervention is required, only the use of palliative care should be used. ²⁴

Associations such as the International Bioethics Committee of UNESCO or the International Council for Medical Sciences are organizations that are dedicated to the work of the ethical regulation of scientific development and research, they do not have a position in favor or against suicidal behavior, however they join forces with various organizations to develop research which is meant to help in suicide prevention. Another moderate position has been proposed by the Hastings Center for Bioethics in the United States, which has not pronounced itself in favor of euthanasia or assisted suicide, nonetheless it does not condemn doctors or patients whose suffering has exceeded the action of palliative support and who see death as the only way to resolve their condition. ²⁵

In Mexico, the National Bioethics Commission (CONBIOETICA) has expressed its stance against medical intervention to assist death, indicating that it is necessary to develop quality palliative care that prioritizes the control of symptoms such as pain, fear, nausea, the sensation of suffocation, among others, through multidisciplinary support involving various specialists: anesthesiologists, algologists, psychiatrists, internists, social workers, nurses, and others. ²⁶ In the civil Mexican scope, there are groups of the population that have organized themselves to express support for the legalization of medical assistance in dying techniques, such as Por el Derecho a Morir con Dignidad (DMD), one of the member societies of the World Federation Right to Die Societies (WFTRDS), whose objective is to bring comfort at the end of life under three strategic areas: palliative care, euthanasia and post-mortem care for the support network. The actions carried out are education, research, dissemination, promotion of public policy actions and empowering the network. ²⁷

An Example of the Debate in Spain

Consensus among laws and ethical codes does not always reach a common point, as is the case with the Organic Law Regulating Euthanasia in Spain (LORE), a statute that came into legal effect in 2021. The LORE contemplates aid in dying as a medical service and stipulates a figure in charge, represented by the physician. The first bioethical position is offered by the Central Commission of Medical Deontology of the General Council of Medical Associations, who do not consider euthanasia as part of the medical act, because it is an attempt against life and the physician's responsibility for preserving it, In the second place, the Code of Ethics of the Council of Medical Associations of Catalonia established a more neutral position by placing respect for the desire, for which a personal declaration or a document of pre-arranged voluntaries is valid, and finally the Social and Health Commission of Ethics Committees of Euskadi (Basque Country) considered it an act of maximum service and professional and human commitment to the patient, when the alternatives of treatment or support have failed to mitigate the intolerable suffering, then euthanasia is morally acceptable. The most important matter is to bear in mind that the physician acting under the protection of the laws of the State cannot be sanctioned deontologically. ²⁸

CONCLUSIÓN

For us to live a full life, it is vital that we are guaranteed respect for our human rights and that at the time of making legislation, situations that prevent the timely approach by the health system and the institutions responsible for ensuring the protection of our rights in mental health issues are contemplated, if we cannot guarantee patients a dignified life, the regulation of assistance procedures for humanized death should be considered, a thought still far away in Mexico. To finish, it is important to emphasize that the moral values of a profession are adapted to the rate of advancement at which a society and its scientific-technological repository advances.