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© Copyright 1998-2010 Related Pages
"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
"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."
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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.
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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.
Clinicians must strive to protect clients from harm. Non-maleficence calls for whatever it takes to assure the client's life.
Clinicians must treat all consistently. Fairness cannot be assumed.
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.
Three distinct forms of suicide may be identified based on the role that a clinician plays in the process:
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.
A somewhat similar typology is offered by Fairbairn (1995)in Contemplating Suicide: The Language and Ethics of Self-Harm:
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
Suicide: An Ethical Typology
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 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.
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 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.
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.
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.
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.)
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.
There is an investigation taking several months. The professional has the chance to respond. Sanctions range from reprimands to expulsion.
State licensure regulations include codes of conduct. Complaints are made to the state board, which can impose serious penalties.
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As a means of redress and to protect others. Professional ethical practices change principally from complaints.
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.
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.
"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
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