More than a single day

More than a single day

“No man is an island, entire of itself; … any man’s death diminishes me, because I am involved in mankind; and therefore, never send to know for whom the bell tolls; it tolls for thee.” JOHN Donne wrote these words four centuries ago, and Ernest Hemingway later used a part of the quote as the title of his novel. The quote describes a principle that modern epidemiology has since validated with data: that no death by suicide is a purely private event. Each death reverberates through a family, a workplace, a community, and, in aggregate, through the statistical and narrative record of a nation’s health. Every year, on Sept 10, the world observes International Suicide Prevention Day, and every year I find myself uneasy with the framing of this ‘observance’. In practice, it so often slides towards something that resembles a commemoration where panels are convened, experts invited, and statistics projected onto screens. The day then passes and is folded back into the calendar — until it comes around again the following year. I do not begrudge any of this; awareness, conversations, panels and specifically data, matter. My unease is narrower and rests in the belief that suicide is not a subject that can be adequately held by a single day, however earnestly it is marked. It is a chronic and distributed public health problem that requires sustained clinical, social, and policy attention throughout the year. The task is to find and reinforce the one thread that tethers the struggling individual to hope. As a physician, I practise under an oath that obliges me to preserve life and relieve suffering, grounded in the biological premise that human beings possess an innate desire to survive. This means that if you are a living creature, you must want to live. This is not simply an ethical assumption; it is observable at a physiological level, in the autonomic responses that mobilise the body against threat and injury. When a patient reaches the point of ending their own life, the clinical interpretation is not that they have uncovered some previously hidden preference for non-existence. Suicidal ideation is clinically read as evidence that they have reached the outer edge of despair, a point at which an underlying and usually treatable condition, often a brain illness like depression, psychoses, substance abuse or something else, has temporarily overwhelmed that baseline instinct to live. Our task, in that moment, is not to argue someone out of their pain, but to identify and reinforce that one thread, however thin, that tethers them to hope and life — long enough for treatment to take effect. Within medicine we often draw an analogy between suicidal crisis and other acute, potentially fatal medical events, such as cardiac arrest, an ischemic stroke, or pulmonary embolism. This comparison is not made lightly. It reflects a genuine clinical understanding that such crises are frequently time-limited, and that patients who receive timely and appropriate care — whether hospitalisation, medication, psychotherapy, or structured follow-up — very often go on to recover and to build lives they later describe as worth living. Understood this way, suicide prevention is less a philosophical argument against a person’s stated wish to die and more a form of emergency medicine: stabilise the acute crisis first, and treat the underlying condition once the immediate danger has passed. And yet, even while holding that conviction firmly, the framework does not fully resolve a question I continue to face in clinical practice. When a terminally ill patient signs a do-not-resuscitate order, declining further intervention as their body finally fails, it is generally regarded as a legitimate exercise of patient autonomy. The ethical basis for distinguishing that decision though, from a decision to end one’s life in the context of prolonged, treatment-resistant psychological suffering is less clear than clinical convention often assumes. At what point does a physician’s judgement that a patient ‘lacks the capacity’ to make such a decision become a form of paternalism rather than clinical care? I do not raise this to suggest that suicide should be approached with anything other than urgent clinical concern; the evidence for the treatability of most suicidal crises is strong, and that evidence should govern practice. I raise it because intellectual honesty requires acknowledging the limits of our current ethical frameworks, and enduring the discomfort of the question, rather than rushing to resolve the tension to avoid facing it. Even so, the clinical and philosophical dimensions of this issue address only part of the picture, because suicide is not solely an individual pathology; it is also a measurable outcome of the socioeconomic conditions in which individuals live. This is particularly relevant to the population now coming of age, and which is confronting a convergence of structural pressures with limited precedent: climate instability, economic contraction, political volatility, widening income inequality, and, more recently, uncertainty about labour market disruption from automation and artificial intelligence. These conditions have not been matched by a corresponding adjustment in social expectations. Academic achievement, career stability, and conventional markers of success remain the default benchmarks, even as the institutional infrastructure that once made those benchmarks attainable has weakened. This mismatch between expectation and structural opportunity is a documented risk factor and a significant contributor to the hopelessness that so often precedes suicidal thinking. Given all of this, a more honest and accurate framing of the annual suicide prevention day is to treat it as an invitation to structured, sustained and evidence-based reflection, individually, clinically, and at the level of policy, on why a species biologically oriented towards survival and social connection continues, in significant and rising numbers, to arrive at a decision to end its own life. That question cannot be resolved within a single day, a single panel discussion, or a single article. It is a question owed, on a continuing basis, to every person currently at risk. Donne’s observation that the bell tolls for all of us remains, four centuries later, an accurate description of what’s at stake. The writer is a consultant child, adolescent and adult psychiatrist and founder & CEO at Synapse Pakistan Neuroscience Institute. Instagram: @lookslikeapsychiatrist Published in Dawn, September 12th, 2026