Suicide prevention must include preventing all suicides.

There seems to me to be a cognitive dissonance in the suicide prevention arena that seems to set aside concern about suicides that are related to advocacy networks such as Exit International. This happens at a number of levels and in a number of ways; some perhaps understandable but none excusable.

Australia has one of the highest incidences of youth suicide in the western world. It makes good sense to focus resources in this critical area of prevention. But there's something missing in the public discussion that should have become crystal clear from recent media coverage in the Fairfax press.

Journalist Craig Butt reports on suicide deaths using Nembutal and highlights its use by young people:

New data from the national coronial information system shows 120 people died by taking Nembutal – dubbed the "peaceful pill" – between July 2000 and December 2012.

The number of deaths from the drug reached a high of 24 in 2011, compared with nine in 2001. In 2012, there were 17 deaths. However, there may be more as the data obtained by Fairfax Media does not include cases before the coroner.'

The deaths included one person under the age of 20, 11 people in their 20s and 14 people in their 30s.

That's 22% of all Nembutal deaths over a little over 11 years being suicides of persons under 40 years of age and 10% under 30 years. The data does not include deaths still under investigation.

Where are the suicide prevention agencies? Nary a comment. True, these deaths comprise only a small percentage of the suicide deaths each year, but that will be of little comfort to family members left to ponder the unanswerable questions, left to grieve. Suicide may be a solitary act, but its effects are far reaching.

True, suicide prevention is not so much about removing or reducing access to particular methods of suicide but, properly, about reaching people with mental health difficulties, keeping them safe and seeking to address their issues. But when their efforts are being critically undermined by clandestine operations and where few are ringing alarm bells about such activities, suicide prevention agencies raising public concern should be a 'no-brainer'. Is this virtual silence tacit endorsement or is something else at play?

To their credit, a number of prevention agencies did respond well to an ABC 7:30 report on the suicide death of West Australian man, Nigel Brayley in 2014 who was shown to have had dealings with Exit International. A connection between Brayley and Exit was well established and at least one of these agencies did respond by making a formal notification to the Australian Medical Board. (Note: the extent of that relationship and whether or not that connection constitutes a breach of the criminal code on assisting in suicide is not proven and I make no inference in that regard.)

It was perhaps this proven connection that prompted action; but that still leaves unanswered the whole question of public suicide advocacy and how that undermines prevention.

There's a further complication that is somewhat understandable but nevertheless inexcusable.

From time to time our media will run stories of older Australians looking to end their lives using methods or substances that are the stock-in-trade of these advocacy networks. In recent times some of these people have been ill, but others simply tired of life with no particular ailment other than the effects of aging.

In general, the media is either neutral or sympathetic in its portrayals including an almost mandatory potted history of the person's life which tends to create an air of sympathy; 'they've had a good life'. There's a different treatment of the suicide of a young person and that of someone at the other end of life's spectrum. Why should this be the case?

Emotions play a big part in our responses. We rightly feel the tragedy of young lives lost and understandably are drawn to the thought that he or she had yet many years ahead of them. We are also easily tempted to thoughts of sympathy or at least understanding at an elder suicide. Aided sometimes by media portrayal, we find some consolation in the thought that they had 'a good life'.

This is quite normal, but it is a very unsound basis for public policy. Suicide is suicide. Regardless of the method, it is a violence against oneself. It is also the ultimate expression of hopelessness, often in a fog of depression where nothing is truly as it seems. Despite what some would say and despite some portrayals in the media, it is never truly a rational act.

But there's also another element at play here; an 'elephant in the room'. The connection between suicide and euthanasia is very real; the only substantive difference is who makes the person dead. Whenever we see stories in our media of an older person who has or who plans to suicide the connection is made between their circumstances and a supposed need for euthanasia laws. Whether their particular circumstances would make them a candidate under particular lawful regime is never discussed but rather assumed.

Add to that the fact that suicide advocates are also intrinsically bound up in euthanasia advocacy and we begin to see, I think, why suicide prevention agencies struggle to articulate concern. It may be that some in the suicide prevention area actively or tacitly support euthanasia; but it is also just as likely, perhaps more likely, that the whole autonomy question bound up with the emotive context of serious illness creates dissonance.

Is the context of a terminal illness really that different that we are prepared as a society to accept that some suicides are okay? Is the context of aging and having had a 'good life' good enough a reason to accept that some suicides are okay? And, ultimately, what is the subtle and maybe not-so-subtle message we are allowing to hold sway in our society if we continue to allow such contexts to undermine or cloud the suicide prevention message? Make no mistake: anything less than total opposition to all suicides tends to support the observation that some suicides are okay; that some lives simply are not worth living.

The Fairfax reporting included the story of Judi Taylor and the death of her son Lucas at age 26 using Nembutal obtained via advice from an online network. When Judi spoke at our conference in Adelaide in May, some three years after Lucas' tragic death, her pain was still evident. Such is the tragedy of suicide; the unanswered questions; the understandable, 'If only…' Judi's courage and that of others who have chosen to speak out, inspires and encourages me. In the midst of all of this, Judi remains thoughtful and charitable when she observed that 'the deaths among younger people were an "unintended consequence" of the voluntary euthanasia movement putting out information online on suicide methods.'

Unintended or not, the consequences of allowing such public advocacy to continue are made painfully obvious in Judi's story. Judi is not alone. There are others; sadly, there most likely will be others.

Can we stop these macabre practices? I don't really know. What I do know is that serious attempts to do so along with a clear, public declaration against such practices, will save lives.

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