Information on the Internet promoting deliberate self harm is perhaps a less discussed domain [1] these information include those promoting deliberate self-harm in the form of self inflicted injuries to taking once own life. Only anecdotal evidence exists on the (mis) use of such information [2] [3] [4], but none has quantified the problem. Moreover, there have been no efforts to collect such evidence systematically. We here discuss the perspectives of Suicide related Information on the Internet, with emphasis on the Ethical concerns and share our experiences with the E-Health Adversities Research Database [E-HARD]

Suicide and the Internet: Anecdotal Evidences

Evidence on the use of Internet for obtaining regulated substances in an attempt of suicide has been reported [2]. Also, evidence on the use of Information on the Internet in suicide also has been reported [3].

Chodorowski and Anand [4] reported a case of suicide instructed by an Internet contact who motivated a 25 year old female student to suicide.

The concerns on rising number of suicide motivating information has been discussed by many [5] [6] [7]

Suicide Information on the Net

To study the prevalence of Suicide information on the Internet, we surveyed the Internet using the search engine Google [8]. The search with the query string "how to suicide" returned 179 hits. A number of websites featured information on different ways of committing suicide.


We also surveyed the Google Directory and retrieved an entire category of 14 websites describing suicide methods [9], out of which only 10 were accessible during the period of study. The websites listed described a variety of methods including gas inhalation, suicide by cop, and other popular methods like hanging, drug over-dosage, shooting oneself etc.

One website discussed in detail how to prepare a suicide note, while one discussed different methods which should be potentially avoided.Two of the websites listed in the Google Directory discussed ancient Japanese suicide methods like Seppuku and Jisatsu.

A survey of the Google Groups and retrieved critical information on three active discussion lists on suicide methods.

Our Experiences with the E-Health Adversities Research Database [E-HARD]

The e-Health Adversities Research Database [11] was created in January 2003 in an attempt to systematically collect evidence regarding adverse health Information and practice over the Internet. The database collects, analyses and publishes submitted evidence regularly. We aim at creating a reliable database of such evidence, based on which future policies and strategies could be planned and implemented to protect the health of the people.


In the last five months [Jan-May 2003], we received submissions regarding five websites providing Suicide Information, out of which three have been published in the e-HARD reports [1]. As our survey reveals, this constitutes only the tip of the iceberg, and our preliminary assessment [unpublished] reveals that such information may range from a few hundreds, close to a thousand web pages. We hope that with further submissions and our increasing exposure to such information, we could probably have glimpse on the epidemiology of suicide information on the Internet.

Ethical Perspectives

The Internet is rightly perceived to be an anarchic and regulation-free environment, and an embodiment of Individual liberty and freedom of expression. The anonymity and regulation free nature of this media along with its ubiquity has contributed to a state in which nobody is responsible to one another. However, this constitutes the worse side of the coin- an inevitable accompaniment of the much-glorified better side- the revolution in information dissemination and access, cannot be potentially overlooked. Unlike other media, which are often amenable to regulation regionally or internationally, -potentially capable of clamping malpractice this virtual world is hard to regulate- given its reach and architecture.

Moreover the impact of such information on potential high risk group visitors like children and individuals with mental diseases like depression need to be taken into consideration. No major research has been conducted to this end.

Discussion

The immediate need is to perhaps quantitatively assess the prevalence of such information promoting deliberate self-harm on the Internet. This would be important in creating a baseline over which further research could be employed. There is also the immediate need to assess the potential impact of such information on the visitors. This could be achieved by observational studies and in-depth analysis in special settings, as well as the submissions to E-HARD and similar databases like DAERI [12].

Possible technology to overcome this strife would also be important. Technology to regulate the access of pornography has evolved over time. Strategies like the PICS Platform [13] offers promise in this direction. In fact the PICS platform is being used to regulate the access of harmful health information by projects like the MedCERTAIN [14] Other possible avenues like midstream filtering[15] using needs to be improved, which could regulate the access of such information via search utilities. 

Other possible avenue is regulation. However, the issue of regulation of Internet has always been a hot topic- involving ethical and other issues, which is out of the scope of this paper, infrastructure to analyse and rate information on the Internet is virtually impossible- given its labile and ephemeral nature and its explosive growth.

In-depth studies and research in this novel domain will possibly contribute to ideas that can aid us in overcoming this quandary. The author hopes that this paper would significantly attract thought, research and resources in this direction.


References

[1] Scaria.V Taking Life on the Web: A case report on three websites submitted to the E-HARD providing suicide related Information.Internet Health 2003 1(1) R1 Also available Online at: http://virtualmed.netfirms.com/internethealth/ehard0103.html 
[2] Cardinale V, FDA coming down harder on illegal on-line drug sales, Drug Topics, Oct. 4, 1999
[3] Athanaselis S, Stefanidou M, Karakoukis N, Koutselinis A
Asphyxial Death by Ether Inhalation and Plastic-bag Suffocation Instructed by the Press and the Internet Journal of Medical Internet Research 2002;4(3):e18 Also available at: http://www.jmir.org/2002/3/e18/ 
[4] Chodorowski Z, Sein Anand J.[Internet as a means of persuading a patient to commit a suicide][Article in Polish]Przegl Lek 2002;59(4-5):375-6
[5] Baume P, Cantor CH, Rolfe A. Cybersuicide: the role of interactive suicide notes on the Internet. Crisis 1997;18(2):73-9
[6] Munro R. Want to know how to behead yourself? Just go online. Nurs Times 2001 Mar 15-21;97(11):12-3
[7] Dobson R.Internet sites may encourage suicide. BMJ 1999 Aug 7;319(7206):337
[8] Google search Engine URL: http://www.google.com {accessed on June 1, 2003}
[9] Google Directory Society>Death>Suicide>methods URL: http://directory.google.com/Top/Society/Death/Suicide/Methods/ {Accessed on May 30, 2003}
[10] How to Kill Yourself. Church of Euthanasia http://www.churchofeuthanasia.org/resources/howtodie.html {Accessed March 20, 2003}
[11] E-Health Adversities Research Database [e-HARD] URL: http://www.cybermedicine.netfirms.com/ehard.html {Accessed June 1, 2003}
[12] Database for Adverse Events related to Internet- DAERI URL: http://www.medcertain.org/daeri 
[13] Platform for Internet Content Selection-PICS URL: http://www.w3.org/PICS/ 
[14] MedCERTAIN.Available from: http://www.medcertain.org/English/About_Us/Overview/overview.htm [accessed 2002 Sept 19]
[15] Scaria V. Thinking of an integrated approach in quality management :involving 'midstream' filtering of Health BMJ Rapid Responses 28 Jun 2002 http://bmj.com/cgi/eletters/324/7337/602#23420 


Source of Funding: None

Competing Interests: None