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Suicide has an ethical dimension. Victims are driven by pain not choice. They are affected by the accumula- tion of risk factors and the diminution of protective factors. Many are in relationships governed by ethical duties. Here are some thoughts on ethics and suicide from a suicide prevention perspective.

© Copyright 1998-2010
Tony Salvatore

Related Pages
    The Suicide Paradigm
    Suicide Loss FAQs
    Suicide Loss Rights
    About Elder Suicide
    Vocabulary of Loss (Glossary)
    Rights Statement for Suicidal Individuals
    Suicide Paradigm Guide (Links)
    Pertinent Sources/Sites

      The Ethical Debate
      Key Points for Debating Assisted Suicide
      "Suicide" Stanford Encyclopedia of Philosophy
      "Suicide and Virtue"
      "Suicide" (Ethics for Schools)
      "Suicide: A Rational Choice?"
      "Does Old Age Make Suicide Ethical?" (Markkula Ctr. for Applied Ethics)
      "The Right to Suicide"
      "Encountering Patient Suicide: Emotional Responses, Ethics, and Implications for Training Programs" (Academic Psychiatry)
      Clinicians as Suicide Survivors
      "Issues to Consider in Intervention Research with Persons at High Risk for Suicidality" (NIMH 2001)
      "Ethical & Legal Issues of Suicide" (Syracuse U.)
      Confidentiality and Client Suicide Risk
      Review of "Fatal Freeedom: The Ethics and Politics of Suicide" (Szasz)
      The Sad Case of Dr. Klavan


      A New Theory of Suicide with Compelling Ethical Implications
      In Why People Die by Suicide (Harvard University Press, 2006)Thomas Joiner offers a comprehensive theory of how suicide happens. Joiner notes that two conditions must be present to overcome the instinct for self-preservation in suicide victims. The first is a desire to die that is brought about by a lost sense of social belonging and the perception that one is a burden. The second is the capacity for lethal self-harm acquired by experience with abuse, pain, past suicidality, and other factors. Both must be present for an individual to complete suicide.

      Is Suicide a Choice?
      "No. Choice implies that a suicidal person can reasonably look at alternatives and select among them. If they could rationally choose, it would not be suicide. Suicide happens when all other alternatives are exhausted -- when no other choices are seen."
      Adina Wrobleski
      Suicide: Why? (1995)

      Using Support Systems
      "The most convenient and ...most useful sources of help for the suicidal person are his friends and family. These people are usually available, they have considerable knowledge of the suicidal person's past history, and it doesn't cost anything to talk to them."
      David Lester
      Making Sense of Suicide (1997)

      Avoiding Ethical Dilemmas
      1. "...Intervention is supposed to help the patient. At regular intervals ask the patient if the treatment is helping.
      2. Stay abreast of developments in the field."
      Chiles and Stroshal
      The Suicidal Patient: Principles of Assessment, Treatment, and Case Management (1995)

      On Suicide Prevention

      "Suicide prevention is like fire prevention. It is not the main mission of any...institution; but it is the minimum ever-present responsibility of each professional; and when the minimal signs of possible fire or suicide are seen, then there are no excuses for holding back on life-saving measures."

      Shneidman, AJN 65(1965)


      "Always, client safety is primary. Even though confidentiality of the suicidal person's communication is important, confidentiality must be reconsidered if a life is at risk."

      Gilliand & James
      Crisis Intervention Strategies (1997)
      "Confidentiality is not a barrier to support, to empathy, to exploring the family's experiences -- their...feelings, their wishes, their guilt, their sadness, and so on."
      T.G. Gutheil

      "Those clinicians who 'believe in' suicide...to the extent that they believe that patients are the best judges of what is best...have simply failed to keep abreast of replicated research in the field. It is a dangerous thing to harbor permissive thoughts about suicde when one has responsibilities for suicidal persons..."

      D.C. Clark (1998) "The Evaluation and Management of the Suicidal Patient" in P.M. Kleespies (Ed.) Emergencies in Mental Health Practice: Evaluation & Management NY: Guilford Press (See also Kleespies et al. "Emergencies with Suicidal Patients: The Input of the Clinician" pp. 379-397)

      "...It is better to be sued for breach of confidentiality than to lose a patient to suicide."

      R. Simon (2007) "Gun Safety Management with Patients at Risk for Suicide" Suicide and Life-Threatening Behavior 37(5)518-526

      The Five B's

      "On the wall of every institute training therapists, there can be a motto known as The Five B's Which Guarantee Dynamic Failure:

      Be Passive
      Be Inactive
      Be Reflective
      Be Silent
      Beware"

      J. Haley (1969) "The Art of Being a Failure as a Therapist" Amer. J. of Orthopsychiatry 39(4) p. 695

      "...the act of suicide...is a 'statement of suffering.' Individuals who attempt or commit suicide are, therefore, overtly communicating at least two key messages: their desperation and their perceived lack of other alternative actions."

      A. Long, A. Long, and A. Smyth (1998) "Suicide: A Statement of Suffering" Nursing Ethics 5(1)

      Launched 06.01.98
      Modified: 6/21/12

The
Ethics Side
of
Suicide

Contents

Professional Ethics and Suicide

The conduct of clinicians is guided by ethics codes that provide nominal protection to suicidal clients. The codes draw on these principles:

  • Autonomy - Respect for the individual self-determination
  • Beneficence - Doing the greatest good possible
  • Non-maleficence - Minimizing or preventing harm
  • Justice - Fairness and equal access to care.

Bioethics has developed responsibilities based on autonomy:

  • Respect for person - The basis of client rights
  • Telling the truth and giving all the facts - Disclosure
  • Confidentiality - Maintaining client privacy
  • Fidelity - Doing the job" and "being there" for the client.

Beneficence is acting in the best interest of clients. Non-maleficence is minimizing harm. Justice is treating individuals fairly.

Autonomy and Suicide

Ethics Audit
for Therapists

a) Do you use a waiver of confidentiality?
b) Do you believe that a "no suicide contract" is a preventative measure?
c) How do you ask about psychological pain (psychache)?
d) What would you do if I became suicidal while in your care?
e) Do your assess- ments consist of "Do you intend to kill yourself?"? Does "NO" mean "No Suicide Risk"?
f) Is risk manange- ment your main concern when confronted by suicide risk?

This principle impacts the clinical response to all suicidal individuals. It calls for respect, dignity, and choice. The last often takes precedence.

Respect for personal rights: This duty sanctifies choice. Suicide is the outcome of psychological debilitation. Extending autonomy to those so afflicted facilitates suicide. Respect for the individual is better served by recognizing their vulnerability.

Telling the truth: Clients at risk deserve candor as to their exposure and means of intervention. Clinicians with strong views about suicide should disclose them or refer the client elsewhere.

Confidentiality:This presents many dilemmas. Suicidality and secrecy are a fatal combination. In some states clinicians may breach confidentiality if the client is a danger to themselves or others. Therapists must disclose if the client is a threat to others. Disclosure of suicidality not mandated.

Fidelity: Clinicians are to be faithful to clients. The risk of suicide must be taken seriously and be acknowledged as the primary problem. Fidelity also demands that clinicians update their views and skills. Outmoded views of suicide put clients at risk.

Beneficence and Suicide

"PRIMUM NON TACERE" (First, do not be silent)
Socratic Maxim


Clinicians must be proactive in working for the client's well-being. Beneficence should not be sacrificed to autonomy if the client is suicidal. Beneficence is caring not just treatment. Every attempt at intervention is warranted.

Non-maleficence and Suicide

Clinicians must strive to protect clients from harm. Non-maleficence calls for whatever it takes to assure the client's life.

Justice and Suicide

Clinicians must treat all consistently. Fairness cannot be assumed.

Concluding Comments

Clinicians often equate what's legal with what's ethical. In most cases, the law sets only minimum standards of conduct. Ethics demands more. This is especially true in regard to suicidal individuals.


Suicide: An Ethical Typology

Three distinct forms of suicide may be identified based on the role that a clinician plays in the process:

  1. Unassisted Suicide
  2. Facilitated Suicide
  3. Assisted Suicide

Unassisted Suicide
This may take two forms. The first applies where the victim completes suicide while not currently or recently in the care of a clinician. The second applies where the victim was currently under care but not for a condition associated with suicidality. The clinician had no basis to assume or suspect risk. The victim did not confide any ideation, plan, or threat or did not acknowledge such behavior if queried by the clinician.

Facilitated Suicide
This applies where the victim completes suicide while currently or recently in the care of a clinician and where these factors were present:
  • A clinical or custodial relationship existed
  • The clinician or provider had knowledge of the risk
  • Means of prevention or intervention were available
A suicide in this context suggests a breach of duty. This could include ignoring the danger, and/or not effectively using resources that may have ameliorated the risk.

In such cases, the suicide has, in effect, been facilitated. This is not to say that the clinician caused the suicide. The ethical failing was doing nothing or acting passively or conservatively despite the client's mortal danger.

Assisted Suicide
This applies where a clinician with knowledge of the individual's wishes and consent enables completion by providing the lethal means and guidance as to use. This mode assumes capacity and rationality. However, most victims of assisted suicide appear driven by extreme stress and/or chronic intractable pain which impair capacity and rationality. Enabling the suicide of such individuals, statutes to the contrary, is unethical.

Volition and Suicide
Assisted suicide is justified, by its advocates, as a personal right. Unassisted suicide is customarily characterized as a personal decision. Where does that leave facilitated suicide? Consider the following:
  • Assisted Suicide = Voluntary Action
  • Facilitated Suicide = Involuntary Action
  • Unassisted Suicide = Nonvoluntary Action

The codes of conduct guiding clinicians are often inadequate in addressing duty to those who are at risk of becoming suicidal or who are suicidal.
Assisted suicide is voluntary when the individual is determined to be capable of independently making the decision. Facilitated suicide is involuntary because the individual made a "cry for help" to a clinician that went unheeded. Unassisted suicide is nonvoluntary in the same way that death as the result of any disease is so.

A somewhat similar typology is offered by Fairbairn (1995)in Contemplating Suicide: The Language and Ethics of Self-Harm:

The most obvious variety of a suicide act involves the suicide actively bringing harm to himself. However, suicide may also be achieved by the direct action of another, by the omissions to act of either the suicide or another, and by the suicide's putting himself in the way of events that he intends and expects to kill him.

For a fuller discussion of this topic see: Anthony Salvatore (2000) "Professional Ethics and Suicide: Toward an Ethical Typology" Ethics, Law, and Aging Review (6) pp. 257-269


Professional Ethics FAQs

Who is covered by codes of ethics?

Counselors and therapists belong to a professional association and are obligated to adhere to a code of ethics as a condition of membership. The code is a statement of standards of conduct towards clients and others. (Ken Pope's site has links to most pertinent professional codes of ethics and material on ethical treatment of individuals at risk of suicide.)

How is an ethical violation be reported?

Each association has a complaint procedure identifying the complainant, the professional, what happened, and when. Witnesses or other sources of substantiation should be given, if available. The complaint is confidential.

What happens after a complaint is made?

There is an investigation taking several months. The professional has the chance to respond. Sanctions range from reprimands to expulsion.

Are there other sources of recourse?

State licensure regulations include codes of conduct. Complaints are made to the state board, which can impose serious penalties.

" I have been struck by how little value our society puts on saving the lives of those who are in such despair as to want to end them." ****Kay Jamison****

Why should an ethics complaint be made?

As a means of redress and to protect others. Professional ethical practices change principally from complaints.

What about when suicide is involved?

The process is more difficult -- there is no victim's account. Only the estate administrator may authorize release of medical information. State boards will use supoenas in compelling cases.


About "Psychological Abandonment"

It is likely that some of the suits pressed by relatives of suicide victims are brought about by the reluctance of some clinicians to communicate meaningfully (if at all) with them because of risk management concerns. "An unfortunate result of this approach may be to produce an air of mystery, uncertainty, and ignorance about what actually occurred -- an atmosphere that may itself foment litigation as a means of simply having family members' questions answered."

See T.G. Gutheil (1992) "Suicide and Suit: Liability After Self-destruction" in D.J. Jacobs (Ed.) Suicide and Clinical Practice Washington DC: American Psychiatric Press.

Caveat on Assisted Suicide

"Assisted suicide and euthanasia would carry us into new terrain. American society has never sanctioned assisted suicide or mercy killing. We believe that the practices would be profoundly dangerous for large segments of the population, especially in light of the widespread failure of American medicine to treat pain adequately or to diagnose and treat depression in many cases. The risks would extend to all individuals who are ill. They would be most severe for those whose autonomy and well-being are already compromised by poverty, lack of access to good medical care, or membership in a stigmatized social group. The risks of legalizing assisted suicide and euthanasia for these individuals, in a health care system and society that cannot effectively protect against the impact of inadequate resources and ingrained social disadvantage, are likely to be extraordinary."

From the Preface
When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context
New York State Department of Health, Task Force on Life and the Law, 2001

Paul 1968-96

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