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"Remember this -- that there is a proper dignity and proportion to be observed in the performance of every act of life."

"Cultivate these, then, for they are wholly within your power: sincerity and dignity; industriousness...Be temperate in manner and speech; carry yourself with authority."

-- Marcus Aurelius, Meditations

Regardless of well-funded research, initiatives, commissions, foundations, mental health first aid, telephone numbers, or other tools distributed for safer suicide care, the absolute number of suicide deaths reached an 80-year peak in 2022. What will it take for "best-practice" authorities to inculcate a new era of dignity, empathy, and integrity in foreseeability, consideration, and competent care of the suicidal person?

As a starting point, I submit that there is worth and value in the scientific imagination, hard work, and deference to the ultra-rare, independent, experienced, and well-trained emergency department (ED) physician-scientist. To emphasize this point on a personal note, I trained in a pioneering emergency psychiatry residency program, and subsequently, I believe I was one of our nation's first formally trained ED adolescent psychiatry fellows.

My mentor, Robert J. Harmon, MD, approached this pioneering fellowship against insurmountable administrative and clinical challenges with steadfast ethical and empathic competency. He demonstrated that these characteristics -- the ability to observe interdisciplinary connections and to try to understand what we see -- were vital prerequisites for the cultivation of reason and wisdom by which suffering is understood and alleviated. This lesson was especially fitting in the early 1980s, and continues horribly today, when access to competent care -- not just care -- is hindered.

I strongly suggest that this example of dedicated and pioneering person-centered clinician-researchers, without pretentiousness or prejudice, is critical to design future innovative work; provide evidence in the regulatory process; ethically attract stakeholders; and translate, modify, and improve competent clinical practice.

As a foundation, empathy and competency are interdependent as they connect the shared feelings of others, the foundation for kindness and trust, and genuinely and benevolently influence teaching and decision-making. Empathy and competency are not final acquisitions. They are acquired over time. Who can deny, for example, the layering of verbal and motor proficiency during child development, integrated intellectual and athletic adeptness of student-athletes, or the mentoring relationship between an experienced clinician and student that involves support and learning?

However, to be sure, entrenched dogma, paternalism, coercion, ostracism, and lack of leadership accountability have effectively obscured these critical elements. Research and treatment inadequacies, bullying of incremental and adroit innovation, imposition of cognitive shortcuts, workforce shortages, training deficiencies, ED personnel burnout, and ineffectively dealt with intolerably complex subject matter add to the toxic mixture of unsuccessful progress. Indeed, these tactics, a likely mix of intentionality and inadvertency, have caused clinicians, sponsors, and the traumatized public to find it nearly impossible to make sense of "gold standard" information, or to trust in those responsible for mental health policy and care.

Furthermore, there continue to be significant problems in conventional suicide investigation that recapitulate these inadequacies. Suicide studies have, for example, tended to focus on traditional, deep-seated, overrepresented constructs such as ideation, depression, hopelessness, and helplessness. Unconventional states have been largely absent from investigation.

Further, suicide studies have summarized large amounts of varied population-level information with unreliable risk recruitment, which future researchers then rely on over time. The result is that stale ideation-centric hypotheses are re-applied in future studies with statistical analyses that do not travel well from one patient population to another, from prevalence to persons.

The current epidemiological evidence tragically confirms that the benefit of asserted, state-of-the-art ideation-centric assessments is not only hard to determine, but inadequate. What, then, does this signal?

1. Current risk assessment, without cross-cut differentiation of symptoms, not diagnosis, is problematic
2. Preoccupation with current risk factor analysis without consideration of different suicide phenotypes -- validly derived, strong, consistent, and epidemiologically plausible -- is not sufficient to foresee suicide
3. Increased suicidal risk in hypothesized low- and high-risk groups may eventually be elucidated by an individual's special vulnerability, including neurologic to heretofore unrecognized unique or combination risk factors
4. Where the demand for mental health services across our country is extreme, and the availability of emergency psychiatrists rarer than rare, who is training the trainers in the stratification and admirably fast triage of dangerousness, with or without an antecedent psychiatric diagnosis

Dimensionality in stratified risk assessment must be reclaimed so that unstable sensitivity, specificity, and positive predictive values are replaced by a new standard of reasonable medical certainty, i.e., Bayes' likelihood ratios and Markov one-step transition probabilities that approach the judicial proof of "beyond a reasonable doubt."

Moreover, current suicide administrative, clinical, research, and educational mental health first-aid authorities who believe "they have seen and understand it all" must be prompted to ask the candid, introspective, and honest question: When have you been involved in the active, painstaking, and arduous observation at the patient's bedside, night after night, day after day, to meticulously document and attempt to understand why some unconventional suicide events unfold as they do? The frank answer is a categorical "no one."

There is no substitute for observation in science. There is no compromise for integrity. There must be self-reflection, honesty, and ethical decision-making. There must be accountability where the inability to detect impending overt self-harm in vulnerable persons remains the tragic rule.

What is seen and unseen is essential to the scientific method and in the collection of data. It cannot be replaced, for it enables the construction of meaningful hypotheses and theories.

As Abraham Lincoln : "I am not bound to win, but I am bound to be true. I am not bound to succeed, but I am bound to live by the light that I have."

As Louis Pasteur , "In the fields of observation chance favors only the prepared mind."

In coherent and well-considered suicide study, dignity, empathy, and integrity should usurp baneful bias, ubiquitous bewilderment, bad science, and pervasive burnout.

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