Abstract
The Internet provides an infinite platform for the portrayal of lethal events. Beyond mere display, however, it dispenses information, allows for participation and sharing of content, and constitutes a virtual interactive forum. The Internet may ultimately shape society's approach to perceiving and dealing with death. Thus, psychiatrists may wish to be aware of these matters so that they may be considered in assessments and clinical care. In this article, the author attempts to identify key online locations where lethality is portrayed and how it may affect the individual patient and practitioner and the population at large.
Willful suspension of disbelief: during psychiatric training, that is the explanation we are given as to how people can actually enjoy the cinematic portrayal of otherwise alarming images. When it comes to violence or death, films have provided an adaptive and perhaps even sublimated avenue for the exploration of aggressive fantasies and the variety of factors surrounding human mortality. Not only is death a matter of interest to many people, but the manner in which it occurs adds abundant dimensions to its perception, be it a natural death or death from illness, accident, suicide, or murder. At some point, it seems as though cinematic portrayal was not sufficient to satisfy the quest for participation in the experience itself; thus, reality shows came about, some with gruesome detail that fueled their sensationalistic appeal. 1000 Ways to Die (Spike TV, 2008–2012) is an example of such a show, although by no means the only one.
However, as our society moved farther into the future, the Internet began playing a more predominant role. It seemed that every aspect of human life and death could be found online. The Internet is easy to access by everyone, with the apparent added benefits of privacy and, in the case of minors, lack of parental oversight. It also allows for contemporaneous monitoring of popularity, sharing of certain subjects, and gathering of social groups in joint appreciation of the content. This phenomenon was well exemplified by the thousands of viewers who logged on to witness the beheadings of captives in 2002 and since then in countries including Iraq, Korea, Libya, and Pakistan.
The concept of death online encompasses several different phenomena that merit discerning. For example, a distinction can be made between being a witness to another person's death and being an active participant in the process. The active participant may propose, enable, encourage, or perpetuate a potentially lethal behavior. Conversely, an active participant may be the interpreter, follower, or victim of the lethal act. Yet another difference is between online portrayal of events that have already happened and are available for repetitive viewing and those that are live-streamed, either in written or audiovisual form.
A case that illustrates some of the concerns that will be discussed in this article is that of Armin Meiwes,1 which occurred in Germany in 2001. Meiwes posted an ad online with details of his search for someone who would agree to being killed and eaten by him. Bernd Jürgen Brandes was the person who answered the ad and consented to the ritual, which was filmed in its entirety (but has since been removed from public online viewing). Although the sexual aspect of vorarephilia and its portrayal online is beyond the scope of this article, the facts surrounding the death itself are pertinent. The case sparked songs, books, television shows, and a film that brought the phenomenon into the world of popular media. Subsequent legal debates have included discussions of insanity, consent, and privacy.2
One may also attempt to broach the subject of deaths shown online on the basis of the situations out of which these events arise. Such an approach has implications for psychiatry and forensic psychiatry. The dimensions of online lethality that will be addressed herein encompass nonsuicidal self-injury, suicide and group suicide, homicide, accidental death, euthanasia, and terrorism.
Suicide and Para-suicidal Behaviors
Pro-suicide websites and videos are easily accessible through the main search engines,3 and they include sites encouraging, promoting, facilitating,4 or displaying suicide. Lewis et al.5 conducted a search of YouTube videos with the keywords of self-injury and self-harm. They selected the 50 most viewed character videos (i.e., featuring a live individual) and the 100 most viewed noncharacter videos (i.e., featuring animated graphics). They documented that YouTube videos showing explicit nonsuicidal injury were common: 90 percent of the noncharacter videos and 28 percent of the character videos had in-action, nonsuicidal self-injury. Fifty-eight percent of the videos did not warn about the content, and 80 percent were accessible without age-based restrictions or parental controls; the top 100 videos analyzed had each been viewed more than two million times.
These freely accessible online videos have come into public awareness perhaps most prominently in Japan, where the phenomenon of suicide among younger individuals, especially through group pacts, has dramatically increased over the past two decades.6 In contrast to offline suicidal pacts or mass suicides, web-based suicidal pacts often are made among strangers who meet online for this purpose.7 In the United States, webcam suicides, or live suicides with an online audience, have become a matter of concern for adolescents.8 Several examples have captured the attention of the public at large through the media, including live suicides by hanging,9 drug overdose,10 or shooting,11 among many others.
An area of particular concern is the availability of recipes for suicide online. The scientific literature has identified cases in which a suicide attempt was based on methods acquired through online websites or forums. The methods included homemade valium,12 hydrogen sulfide,13,14 tobacco-extracted nicotine,15,16 barbiturate acquisition through the web,17 asphyxiation by helium gas,18 yew poisoning,19 ether and plastic bag suffocation,20 and beheading.21
Euthanasia, Accidental Deaths, and Homicide
Euthanasia websites may be classified as pro- or antieuthanasia and are also easily accessible through the major search engines.22 Accidental death videos and pictures abound and are easily found and include those involving cars, power machines, and sports and recreation.23 Similarly, a search for homicide videos, quickly yields graphic images and videos pertaining to murder.24 There are also websites that provide links to material encompassing lethal events of all sorts.25 Finally, the online demand for items that belonged to murderers or their victims (so-called murderabilia) has risen dramatically, with many websites devoted to collecting or selling these items.
A question that comes to mind pertains to the motivations of individuals who access these websites. A study26 conducted in Japan pertaining to suicide websites identified four factors: helping others, unburdening oneself, finding a way out, and preparing for suicide. Subsequent cluster analysis identified desires to help or counsel others, highly suicidal intentions, and unspecified motives. Motivation is also of particular importance when determining if the cause of death was accidental or suicidal. For example, in the case of a hanging, accidental autoerotic death versus suicide might come into question.27 Another variation where motivation becomes crucial is in suicidal terrorist attacks, which may be motivated by religious beliefs, such as opposition to a perceived global evil,28 and, therefore, require global dissemination through avenues like the web to communicate the perpetrators' ultimate message. Understanding the motivations for witnessing lethal events online may help explain why websites offering this material continue to expand.
Sources of Support
Support websites for suicidal individuals are available29 (e.g., SAHAR, Befrienders,30 and Metanoia), offering information, support, help, or prevention therapy. In the United States, the Preventing Suicide Network, funded by the National Institute of Mental Health, offers an online community support intermediary for the purposes of education and prevention.31 The Lancet recently published a study concerning the role of the Internet as a suicide prevention avenue,32 and a German study33 found consistent reports that indicate an overrepresentation of suicide-preventing websites over those that promote it. Similarly, a study34 found that a sample of people bereaved by suicide found support in online community forums, with few adverse consequences mentioned. In interviews, suicide website users35 reported that they found the websites to be communities offering empathy and understanding and a way of coping with social and psychological distress. Social support was found to be higher in suicide forums where discussion of suicide methods did not occur, and it correlated with participants' ratings of reduction of suicidality.36
Unfortunately, a recent analysis37 of Canadian websites found that only 40 percent of those containing information on suicide provided statements supported by evidence regarding risk factors or prevention strategies for suicide. Similarly, a study of Dutch websites38 found that the information contained in sites dealing with suicide was not optimal, with most deficiencies identified in the areas of e-help and interactive possibilities.
Peer-to-peer support interventions have been proposed,39 given the identification of a high-risk group of individuals who seek out pro-suicide websites and have high-risk suicidal traits, but also find less social alienation and significant support in the online community.
A particular challenge lies in the fact that the best method of support or intervention has not been established through scientific research. For example, a study40 found that while telephone crisis interventions have been deemed more effective, asynchronous (i.e., communications via e-mail or media messages that are responded to at a later time) reports of suicidality were more frequent than those made in live chats or by telephone. Perhaps asynchronous communication elicits suicidal ideation earlier, and thus offers the opportunity for intervention before the moment of crisis.
The counterargument proposes that participation in suicide forums may increase suicidality, either by imitation or contagion (often called suicide by Internet). The Internet's information accessibility, particularly in regard to methods of suicide, may trigger suicidal behavior in vulnerable individuals, such as adolescents.35 While the impact on youths has perhaps been the most studied, a positive correlation between Internet users and suicides in the general population,41 as well as with elderly suicides, has also been identified.42 Furthermore, there is increasing concern regarding the fact that these websites may glamorize or encourage death. Some Internet websites may discourage people with mental illness from seeking psychiatric help, may condone suicide, or may forbid entry to anyone offering to discourage users from committing suicide.43
From a more neutral perspective, there is also an argument to be made regarding the availability of materials online that would allow for scientific analysis of the phenomenon. Along these lines, Lester44 attempted to conduct a linguistic analysis of the blog of a person who committed a murder-suicide and found that it had no similarities to the person's offline diary. The Internet may also be a source of information that assists in the study of risk factors or warning signs of suicide, which may ultimately inform the field. However, no consensus on suicide warning signs has been identified.45 Barak and Miron46 used material written online and concluded that highly suicidal individuals differ significantly from emotionally distressed nonsuicidal and nondistressed individuals. Specifically, suicidal individuals attributed their distress to more global factors, had higher self-focus, and expressed psychological themes with more psychic pain and cognitive constriction.
It must be noted, however, that research regarding this phenomenon and its impact on clinical outcomes is limited, and most data are based on isolated reports or the observation of small groups. Few systematic or closely scrutinized investigations have been conducted, particularly with regard to other aspects of lethality beyond suicidal or para-suicidal behavior.
Phenomenology
Beyond personal motivation to witness, participate in, or create lethality material online, one must consider other phenomenological dimensions of its presence.
In psychiatric treatment, normalization of behavior often decreases subjective distress by offering a source of validation and perceived empathic support. However, extreme normalization may give way to a loss of intimacy, impairment of the development of a fully individualized ego, and loss of an observing ego that can provide the subject with a moral compass and theory of mind.
Discursive psychology studies47 have revealed that suicide forums at times may act as a space for suicidal identities to be tested as they develop into full suicidal authenticity. This progression occurs through practices such as narrative formatting, which is validated and authenticated by other participants. In this way, being depressed becomes a matter of doing (as in the act of committing suicide) and provides a shift in the agent from a passive to an active status. Similarly, onsite sharing allows for concretizing and enactment of otherwise forbidden, bizarre, or pathological fantasies, such as cannibalism.48
From a subjective approach, one must consider the existential aspects of the choice to die and the intersubjective role of the group in the decision-making process, especially in non-mentally ill individuals. Subjective analysis allows for exploration of the meaning of loss, the concept of life's worth (or ikigai, the absence thereof), and the view of suicide as a mechanism for healing.49
Ozawa-De Silva50 argued that the phenomenon of group suicide may arise from the need of social connectedness and the subsequent fear of social rejection. In cultures such as in Japan, where the dichotomy between agency and social structure is more nuanced, the sense of self is closely associated with the social self as perceived and experienced by others. In the virtual world, physical boundaries are blurred, thus promoting an enmeshment with the online community and a dissipation of the margin between the real and unreal ego.
Law and Regulation
The legal regulation of these online phenomena poses a particular challenge pertaining to jurisdiction. Legal regulation may vary among countries, and off-shore websites may remain immune to regulation. Website regulation may therefore vary in proinjury content, as well as in regulatory norms regarding advice or counsel provided to vulnerable individuals.
Australia criminalized pro-suicide websites in 2006,51 and the action sparked a heated debate that concerned the right of free speech52 and the autonomy of people who have a legitimate wish to die. In the United States, courts faced the matter of assisted suicide in 2003 in two cases. One was a civil suit involving the suicide by hanging of a 21-year-old who had clearly viewed a website with detailed instructions on how to commit such a suicide. Another was a criminal investigation in which a pro-suicide organization published a website that was the source of detailed instructions used by a 52-year-old woman to commit suicide by helium intoxication.53
In the United Kingdom, pro-suicide websites are regulated by the Suicide Act of 196154 and its amendment of 2009.55 This amendment speaks to the matter of liability for assisting or attempting to assist a person in committing suicide, both online and offline, while the original statute spoke to liability for assisting and encouraging crime.56 Under Section 2 of the original Suicide Act, it was an offense to “aid, abet, counsel or procure the suicide of another or an attempt by another to commit suicide.”54 However, in Section 1, the Suicide Act of 1961 also decriminalized suicide, creating the interesting legislative intent that it can be a crime to assist someone in the commission of an act that is not itself a crime. Mere provision of information on how to commit suicide, however, did not meet the definition of assisting another person to commit or attempt suicide. The law requires the accused's knowledge that the act will, in fact, occur, as well as proof that the person who commits or attempts suicide is aided by the defendant's actions.
The Criminal Attempts Act of 198156 created the offense of attempt, which does not require knowledge that an act will in fact occur, but rather judges the person based on what he or she thought would occur, given the facts of the situation available at the time of the attempt. The Act applies to all indictable offenses with the specific exceptions of conspiracy, aiding, and abetting. It has been used, however, to prosecute individuals for encouraging or inciting another person to commit suicide, and it does not require that the person thus encouraged later commit or form the intention to commit suicide (Ref. 54, Appendix B: Suicides: Aided or Assisted?, Sections B.18 & B.19), but only that the accused intends to aid a person in committing or attempting suicide.
Both of these legislative schemes were used to prosecute those who provide information about committing suicide online,55 but the legislation still had practical limitations. For example, in 2007 a man offered (online) to assist an undercover reporter in committing suicide. He was charged but was not convicted, because a face-to-face meeting with the purportedly suicidal reporter never occurred.57
The confusion of these two separate statutory schemes was resolved in Section 59 of the Coroners and Justice Act of 2009, by which the Criminal Attempts Act of 1981 was no longer considered applicable to Section 2 of the Suicide Act.55 There is now a single offense for assisting or attempting to assist suicide:
The offense will apply where a person does an act which is capable of encouraging or assisting another person to commit or attempt to commit suicide, and intends his act to so encourage or assist. The person committing the offense need not know the other person or even be able to identify them [Ref. 55, § 10].
Some58 have proposed parental regulation and filtering as a way to control viewing of potentially harmful information on the Internet by vulnerable adolescents. Legal regulation would thus emphasize the custodian's role over that of the state in ensuring safety. From a different angle, some have proposed that the media should be penalized for reporting or glamorizing tragic online events,59 or that media guidelines should be applied to websites to regulate their content.60 In Japan, four Internet Service Providers (ISPs) proposed a voluntary regulatory guideline in October 2005 under which users identified in pro-suicide websites are automatically reported to the police.61
From a medical perspective, the Health on the Net (HON) Organization, derived from the World Health Organization, was established in an effort to review and regulate health information available on the Internet. It set forth what is known as the HON Code of Conduct, which specifies certain criteria for evaluating medical and health websites. The HON Code62 may be used as a reference for regulation of some websites that address lethality, especially if they speak to matters such as euthanasia.63 To promote regulation and information on euthanasia, the United States and Canada created a joint endeavor called DeathNET,64 a site containing regulations and commentaries regarding matters and cases of euthanasia. Unfortunately, the website is not currently available for review.
On a more personal and less legislative level, associations such as Eshnav65 have emerged, promoting a morally conscious use of the Internet and its technological resources, especially in matters related to life and death decisions. They propose an approach based on respectful and prudent publishing of information, as well as the exercise of sound judgment when referring to such matters, rather than relying on regulatory agencies for control of content.
Implications for Clinical and Forensic Practice
An immediate dimension in which clinicians may see themselves involved in this matter would be in the astute suspicion and identification of suicidality. As noted earlier, individuals who use web-suggested methods may not present for clinical care with common or typical syndromes that clinicians have experience in evaluating, or they may prefer a method that is difficult to detect by conventional screenings, as may be the case in yew poisoning or nicotine overdose, for example.
Following that line of thinking, perhaps it is time for clinicians to start thinking of the Internet as a collateral informant and of the need for conducting an Internet history as a routine part of the psychiatric assessment.66 In complex or unclear cases, public information available on the Internet may provide valuable insights as to the patient's history, reliability, and risk. For example, Neimark et al.67 documented a case where the risk assessment of suicide would have been inaccurately low, had it not been for a discovery of a suicidal history of the patient through a Google search. Similarly, Powsner and Kennedy68 and Van Rhoades and Caplan69 used the Internet to discover a patient's posted threats to kill his school's principal, other students, and himself. Some considerations to be taken into account within the legal realm include matters of confidentiality and duty to warn or protect, proper risk assessment, and the provision of information or directives that could establish a duty. In the case of euthanasia websites, physicians may be implicated in the question of physician-assisted suicide, especially when including jurisdictions that differ in their legislation on this matter.
Conclusions
Society continues to move deeper into the era of the Internet and its many dimensions, with more and new demands for its uncritical acceptance. As this virtual world develops, it provides avenues for information and communication or exchange, including communication that may be viewed as unhealthy or even criminal. It may serve to aid and abet those who witness and participate in lethality events on the web. Therefore, it is important for mental health professionals to consider the implications of these developments from clinical, legal, societal, and ethics perspectives.
Legal implications concerning witnessing or participating in these events, live-stream viewing as a source of informing the public, and the details in matters of lethality lead to further analysis regarding the acquired responsibilities of all who intervene or participate in these behaviors or events, including websites and clinicians. Not only do legal questions arise regarding legal regulation of these websites, but societal repercussions must be considered when the ease and speed with which the details of lethality and violent death are presented may lead the viewer to set aside previously held values and beliefs.
The question of motivation does, of course, play a part in this choice, too. Websites of this nature might, indeed, set forth the explanation that viewers partake in these activities to find comfort, company, advice, or solace; these might, therefore, be seen as their source of defense. By extension, these sites may also provide an outlet for satisfaction or enactment of drives and behaviors such as voyeurism, sadism, and masochism. Yet another question arises: how should psychiatry and, more precisely, forensic psychiatry address the alarmingly increasing numbers of websites? What can and should be done? As the participants in these websites exercise their right to free speech, how are they subject to the accompanying responsibilities?
Online posting of gruesome details of lethal violence and suicidal strategies for the purposes of entertainment of viewers raises questions of consent, privacy, and freedom of speech. Such practices beg for revisiting and redefining the limitations and extension of the law and the manner in which treating psychiatrists and forensic practitioners conduct their assessments to include the online world. The behavior of persons online, as well as the impact that the Internet may have on their lives and well-being must be incorporated into the assessment interviews. Online lethality has, willingly or unwillingly, involved all participants, from the Internet to parents and their role as supervisors, to those with a role in the clinical and legal systems. The blurred boundaries of the virtual world should no longer lead to the willful suspension of disbelief; they should now lead to a more subjective approach, because Internet-inspired suicide and lethality no longer occur after the fact, with live deaths online allowing for real-time presence and demanding real-time responses.
Footnotes
-
Disclosures of financial or other potential conflicts of interest: None.
- © 2012 American Academy of Psychiatry and the Law
References
- 1.↵
- 2.↵
- 3.↵
- 4.↵
- 5.↵
- 6.↵
- 7.↵
- 8.↵
- 9.↵
- 10.↵
- 11.↵
- 12.↵
- 13.↵
- 14.↵
- 15.↵
- 16.↵
- 17.↵
- 18.↵
- 19.↵
- 20.↵
- 21.↵
- 22.↵
- 23.↵
- 24.↵
- 25.↵
- 26.↵
- 27.↵
- 28.↵
- 29.↵
- 30.↵
- 31.↵
- 32.↵
- 33.↵
- 34.↵
- 35.↵
- 36.↵
- 37.↵
- 38.↵
- 39.↵
- 40.↵
- 41.↵
- 42.↵
- 43.↵
- 44.↵
- 45.↵
- 46.↵
- 47.↵
- 48.↵
- 49.↵
- 50.↵
- 51.↵
- 52.↵
- 53.↵
- 54.↵
- 55.↵
- 56.↵
- 57.↵
- 58.↵
- 59.↵
- 60.↵
- 61.↵
- 62.↵
- 63.↵
- 64.↵
- 65.↵
- 66.↵
- 67.↵
- 68.↵
- 69.↵
