Quadruple pact suicide attempt involving a man and three adolescents.

Pact suicides involving families have been reported in the scientific literature, but reports have been few from India. We report the case of a family, in which the father and three children had entered into a suicidal pact and executed it due to social reasons. A 41-year-old man, with no past psychiatric or substance use history, had reportedly come to know that his wife had been involved in an extra-marital affair. As expressed by him in a suicide note, he could not bear the humiliation due to this and also did not want his children to face disrespect from the society. He along with his daughter and 2 sons, aged 14, 12 and 11 years respectively, thus entered into a suicide pact to end their lives and wrote a suicide note. Man and two of his children consumed aluminum phosphide. However, the youngest son did not consume the poison and raised alarm, following which they were rushed for medical care. The father died, but the three children recovered completely. The case highlights the rare phenomenon of suicide pacts involving an adult and children.

INTRODUCTION

Pact suicides are those wherein two or more individuals mutually agree and execute to terminate their lives together.[12] The individuals involved in pact suicides have been usually two adults. Only occasional reports have reported triple pact suicide, which involved three persons.[3] Pact suicides involving consenting or assenting children have been less frequent.[234] Pact suicides have been most commonly reported from Japan.[5] The usual profile of persons involved in pact suicides includes those females, older, married and of high social class.[1]

If one relies on the media reports, whenever two or more deaths occur together, one of whom is a child; it is usually considered as a homicide-suicide without the consent of the child. For establishing that the suicides were an outcome of suicide pact, objective evidence in the form of a suicide note is required to establish that the deaths were an outcome of suicide pact. In Indian context, pact suicides generally involve issueless couples, disappointed lovers, unmarried sisters, frustrated individuals or a woman ending her own life and that of her children due to family circumstances or financial difficulties.[6]

When many people commit suicide together, it is known as mass suicide. This usually occurs in the religious, political or military reasons.[78] In our literature search, we did not come across a pact suicide involving four persons (quadruple pact suicide). In this report, we describe a family (of four persons, three of whom were adolescents), which entered into a pact suicide due to the social reasons.

CASE REPORT

A man and his three children were brought to the emergency department by their neighbors. He and two of the children had allegedly consumed celphos (aluminum phosphide) tablets, which is a commonly used insecticide in this part of India. The father was found to have respiratory distress and had to be immediately intubated and ventilated. The two children were hemodynamically stable and were managed conservatively. The third (youngest) child was found to have minor head injuries. Detail information was obtained from the neighbors who had brought them and the third child.

The man was educated up to 10th standard and was employed. He reportedly had no past psychiatric or substance use history. He was managing a nuclear family with his wife and three children of ages 14 (girl), 12 (boy) and 11 (boy) years. There were no significant financial difficulties and no significant marital discord. Two days prior to the alleged suicidal attempt, the man came to know about the extra-marital relationship of his wife. According to the informants, the fact that she was having and extra-marital relationship was true and the extra-marital relationship was continuing for a long time prior to patient coming to know about the same. Children also came to know about the issue during the same time. All of them felt distress and humiliated. Due to extreme distress, man discussed the issue of humiliation with his children, who all agreed that they were also having the same distressing emotions and did not know how to face the society. Following which the man suggested to his children that, it would be best to end life to escape the humiliation from the society. As per the information provided by the child who had escaped with only minor head injury, all of them agreed to end their life and signed a suicide pact, for the same. The following morning, the man procured eight tablets of aluminum phosphide from a local vendor. After ensuring that the house was securely closed, the man handed over two tablets of aluminum phosphide to each of his three children. He consumed two tablets himself and asked his children to follow the same. The two elder children consumed the tablets, but as the turn of the youngest son's came, he tried to run toward a window to escape. To prevent him from escaping the man threw a blunt object, which hit the youngest son on his head, but he managed to escape and raised alarm for help. Within minutes, several villagers rushed toward their home and when they managed to break open, they reportedly found the man and the two children vomiting profusely. They were initially shifted to a local primary care health center and gastric lavage was done. However, the physical status of the man and the two elder children worsened, which led to patients being shifted to our emergency.

Besides intubating and providing ventilatory support the man could not be saved and he succumbed to the aluminum phosphide toxicity. However, the elder son and the daughter improved with the medical support. The youngest child, who described the whole event, did not have any evidence of intracranial bleeding on the computerized tomography of the brain. All the three children were provided psychological support to deal with the traumatic events.

DISCUSSION

Our report describes pact suicide involving four persons, three of whom were adolescents. There were certain unique features involving this case. The description of pact suicide involving an adult and a child usually describe the involvement of a mother and her child,[9] in contrast in the present case the pact suicide involved father and children. In the majority of the pact suicides, the two persons who enter into a pact to end their life do so to avoid separation from each other because of love and closeness among themselves. In contrast, in the case described by us, the people who entered the pact did the same so as to avoid social humiliation.

Further, this case suggests that many a time's children do enter into a pact to end their life impulsively without understanding the consequences. This was highlighted by the behavior of the youngest child in our report, who initially agreed to end his life along with other family members, but later tried to escape when he realized the consequences. This fact reflects that adolescents are very vulnerable and many of them may be suggestible to execute the act of self-harm. Another unique situation, which was seen in this case, was that three of the persons who entered the pact survived and only one lost his life. Occasional reports involving pact suicide have given similar descriptions of one of the survivors who is usually a co-operator, rather than the instigator.[1011]

In the present report too, the pact suicide was preceded by a psychosocial stressor, in otherwise well-adjusted individual as has been observed in many of the previous reports from India.[61213] In contrast to the commonly described cases of mass suicide, which involves many people for religious, political or military reasons, the current case highlights quadruple pact suicide following a social stressor.

From a legal standpoint, the case suggests that the children were influenced to sign on to the suicide note and commit suicide. The mere act of attempting to commit suicide is punishable as per the Indian Penal Code (section 309). However, the survivors being minors may absolve the children of responsibility and hence a trial. Otherwise too, punitive measures toward suicide attempt survivors have been debated.[14]