THE
ECONOMIC COSTS OF SUICIDE: A REVIEW OF CITATIONS TO “RECALCULATING THE ECONOMIC
COST OF SUICIDE”
David
Lester & Bijou Yang
Abstract: An analysis of 91
citations for an article by Yang and Lester (2007), which argued that suicides
result in savings to the society, showed that only 9 reported Yang and Lester’s
thesis correctly, and only one article conducted a serious discussion of the issues
raised by Yang and Lester.
Viscusi (1984) argued that the financial
savings from the premature deaths of those who smoke cigarettes (as a results
of reduced nursing home care costs and pension and social security payouts) were
greater than the costs of medical care and life insurance. Viscusi calculated
that each pack of cigarettes sold saves the society $0.72.
Yang and Lester (2007) applied Viscusi’s
arguments to those who die by suicide. Suicides results in savings from healthcare
and nursing home costs later in life, as well as pension and social security
payouts. When estimating the loss from future earnings by suicides, researchers
typically forget that suicides may not be the most productive members of society.
Many psychiatric researchers (e.g., Robins, 1981) argue that almost all
suicides merit a psychiatric diagnosis, often a severe and disabling
psychiatric disorder, and so their future earnings may be far lower than those
of average citizens. Their psychiatric disorder may also incur large economic
costs for psychiatric treatment had they lived.
Yang and Lester
estimated the cost of suicides in 2005 in the USA to be $16.83 billion, the
savings from not having to treat the psychiatric disorders of the suicides had
they continued to live to be $8. 11 billion, the savings from pensions and
nursing home care to be $12.99 billion, and the savings from assisted suicide
to be $0.80 billion, giving a net savings from the suicides to be $5.07 billion
in 2005 dollars.
As of the time of writing this article,
Yang and Lester (2007) had 91 citations noted in Google Scholar. That seems to
be impressive. The present review examined these 91 citations to see how they
cited Yang and Lester.
Reviewing
the Citations
Google Scholar examines
a variety of writings for citations, including, of course, articles in
scholarly journals and books, but also dissertations, blogs and unpublished papers
uploaded to websites such as ResearchGate. This is an impressive achievement,
but Google Scholar citations are, therefore, not restricted to scholarly publications.
Thirteen of the
citations were not in English and so not examined for this review. Five authors
simply included a reference to Yang and Lester is a list of references without
mentioning the article in the text, and two “citations” did not contain any
reference to Yang and Lester.
On six occasions, the same article was
included twice, for example, as a pre-print on a university website and as the
published article.
Seven articles misquoted Yang and
Lester. For example, Savage (2018) said that Yang and Lester discussed the
rationality of suicide. This was not the focus of Yang and Lester. Other misquotes
were made by Fredette (2014), Li and Zhang, (2010), Ring, et al. (2015), Rivera,
et al. (2017), Saleh (2016), while others simply included a non-specific citation
to Yang and Lester in a series of cites, such as 1-21 (Poduri, 2016).
Yang and Lester
reviewed briefly research on the estimated costs to the society of attempted
suicide, although Yang and Lester did not present new calculations, and 20 articles
quoted Yang and Lester for the estimated costs of attempted suicide (Barrigan,
et al., 2022; Bolton, et al., 2015; Brann, et al., 2021; Francisco,
et al., 2020; Ghahramanlou-Holloway, et al., 2012; Gysin-Maillart, et al.,
2016; Keefner & Stenvig, 2021; Kim,
et al., 2022; Kochanski, 2012; Lee, 2016; Lynch, 2014; Mickle, 2011; Milner
& De Leo, 2010; Murrell, et al., 2014; Myrick, et al., 2017; Polits, 2016; Rothes,
2014; Sheftall, et al., 2013; Shepard, et al., 2016; Woodland, 2014).
Twenty authors
cited Yang and Lester for saying completed suicide incurs costs for the
society, which is the opposite of what Yang and Lester argued (Bermeo, 2019; Bolton,
et al., 2015[1]:
Brann, et al., 2021; Dunn, 2013; Johnston, 2013; Kim, et al., 2022; Kirigia, et
al., 2020; Layden, 2017; Lynch, 2014; Moutier, 2014; Murphy, et al., 2021; O’Brien,
2010; Onoya, et al., 2021; Rothes, 2014; Sand, 2012; Sels, et al., 2021; Sheehan,
et al., 2019; Singer, et al., 2022; Tondo, et al., 2008; Vannoy[2],
et al., 2010). These 20 authors do not appear to have understood Yang and
Lester’s thesis.
Kinchin and Doran
(2017, 2018) looked at the cost of suicide in Australia. As well as calculating
the cost of the legal and medical procedures following a suicide (direct
costs), they also estimated the loss of economic productivity resulting from
the lost years of life, but they admit that they ignored the savings discussed
by Yang and Lester. A similar tactic of ignoring the essence of Yang and
Lester’s analysis was made by Shepard, et al. (2016)[3]
and Alfonso-Sánchez, et al. (2020). Others simply ignored Yang and Lester
without mentioning that they were ignoring their argument (Lyszczarz, 2021).
Seven authors
cited Yang and Lester correctly, admitting that suicides can result in an
economic benefit for the society (Gunn, 2019; Ohayi, 2019; Snow, et al., 2016; Sueki,
2016; Torp, 2014; Ying & Chang, 2009; Zak, 2015). Luckily, two self-citations
also correctly reported the results of Yang and Lester. Two more researchers
cited the thesis of Yang and Lester correctly and did additional calculations
(see the next section).
Research on the Economic
Cost of Suicide
Sarma (2018) estimated
the economic cost of suicides in India is 2015 and did consider both economic losses
and gains resulting from those suicides, but he calculated that the losses far
exceeded the gains.
The most complete
discussion of Yang and Lester’s article was made by Stack (2007). Stack drew
attention to three issues. First, although it is true that suicides, by dying
at a younger age than those dying from other causes, save on the direct costs
of healthcare (medical and psychiatric), the longer people survive, the more
healthcare jobs created. In this regard, suicides incur a cost to the society.
Second, the costs
incurred by those grieving for those who died by suicide may differ from the
costs incurred by those grieving for those dying of other causes. Stack noted that
suicides are typically sudden deaths, a factor which may affect grieving. On
the other hand, suicides typically have smaller social networks than those
dying from other causes, and so there are fewer people grieving.
Third, Stack
argued that Yang and Lester overestimated the costs of healthcare for suicides.
In his discussion, Stack focused on what percentage of suicides sought mental
health treatment in the last year of their life. However, Stack also noted that
the average age at death was 45 for suicides, and so they avoid roughly 30
years of life. It is during these 30 years that healthcare costs may be large.
Discussion
\
The present analysis of citations to
our article indicates that citations may not be a valid measure of the significance
of an article. Only nine researchers cited Yang and Lester’s article correctly,
and only one (Stack, 2007) conducted a serious discussion of the issues raised
by Yang and Lester. In the years since 2007, the thesis of Yang and Lester’s article
has died a natural death.
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