JAMA
Vol. 286 No. 8, August 22/29, 2001

A Story About Suicide in the Arctic

To the Editor: In his A Piece of My Mind article entitled "Five Miles From Tomorrow," Dr. Shah¹ describes an elderly Inuit man who was seen at our clinic, and who was said to end his life by walking into the ocean. I remember well Shah's medical student rotation with us last year, and I enjoyed the week that we spent together. As his supervising physician during that week, I believe that his story deserves a response.

I appreciate Shah's story for the questions it raises about respecting end-of-life wishes, whether or not they occur in the context of an intensive care unit or a remote arctic village. However, the subtleties and complexities of real-life medicine are better appreciated in case illustrations when they have some basis in reality. Shah's article is presented as a true story, when in fact there is little truth about it. I can understand Shah wanting to change details to protect confidentiality. I can even understand his wanting to "tweak" his description of the events a little to make it a better story. But Shah's story goes beyond such editorial adjustments: the events described in his story never happened.

There was no elder who came to us with a complaint of "uselessness" or with the intent of "saying good-bye." There has never been a Siberian Yupik tradition that an elder "bids farewell to his family and walks over the frozen Arctic Ocean, never to return." Shah's story perpetuates a falsehood that has never been true among the Inuit of Alaska. Theirs is not "a culture that feels a man is only as valuable as the wisdom he imparts." As in all Inuit cultures, the Siberian Yupik hold their elders in very high esteem—partly because of their role as reservoirs of cultural traditions and wisdom, but mostly just because they are the elders. They are intrinsically valued as indispensable members of the community. Nor is the arctic a "harsh land of limited resources" where such a tradition might evolve. To the Inuit, the land is bountiful and beautiful, an inextricable element of their cultural identity that has always provided what is needed for their survival.

Being fiction does not necessarily detract from the value of Shah's story. As a piece of fiction, this is a nice story that offers an insightful reflection on our own cultural prejudices: when so much of a person's status depends upon performance and achievements, suicide might become a reasonable option for uselessness. But an elder faced with such despair would be far more common within our own culture than he would among the Siberian Yupik.

Michael D. Swenson, MD, PhD
Norton Sound Health Corporation
Nome, Alaska

1. Shah S. Five miles from tomorrow. JAMA. 2000;284:1897-1898.

In Reply: Although I appreciated Dr. Swenson's teaching and clinical insights, his criticisms of the story bear little relation to the larger issues of cultural sensitivity and end-of-life care that the story addressed.

Swenson complains that the story is written as a first-person account; no such event took place during our week in the Arctic. However, this does not mean that such events do not occur in the village I was writing about. Several residents and patients in Nome related similar stories throughout my 5-week stay. As I wrote the story, I was aware of the need to condense events to present a formalized and palatable essay—one that would raise the pertinent issues of medicine and cultural context in a readable format. This was necessary to protect patient confidentiality and falls well within the limits of artistic license. Swenson himself acknowledges both these needs, stating he understands the need to alter events ". . . to make it a better story." Thus, the ultimate purpose of the story was hopefully served, and the medical community can concentrate more on end-of-life issues and less on stylized writing.

No one doubts elders in the Yupik culture are held in high esteem by their peers. I purposely noted this in my story, which mentions the patient's ability to impart mastered skills to others. However, being held in high regard by peers does not necessarily translate to feeling useful in a part of the world where living is extremely difficult. Such feelings have, I believe, led several older members of Inuit to take the actions I discussed.

Shetal I. Shah, MD
Durham, NC

Editor's Note: At the time Dr. Shah's manuscript was accepted, the editors believed that the essay represented his actual experience. The author's cover letter of submission states: "The story represents an experience I had an [sic] a visiting medical student in the remote village of Gambell, Alaska."