ETHICAL ISSUES AND SUICIDE

Healthcare providers are guided by a code of ethics based on these principles:

Autonomy: Respect for the individual’s self-determination
Beneficence: Doing the greatest possible good
Nonmaleficence: Preventing or minimizing harm
Justice: Fairness and equal access to care

Suicide prevention, however, offers several ethical dilemmas. Emergent intervention may include:

Actions taken without the individual’s consent
Actions which limit a person’s freedom
Actions which often feel and are disempowering

These challenge ethical imperatives, including:

The right of a person to autonomous choice versus the need to protect vulnerable people (do no harm)
Confidentiality versus the release or solicitation of information in order to prevent harm
Freedom of choice to decide to live or die versus everything necessary should be done to preserve life

Involuntary hospitalizations and compulsory treatment can raise legal and ethical issues, as they violate basic civil rights, restrict the freedom of individuals, and impose significant responsibilities on physicians. This high sense of responsibility may cause physicians to cross their limits and ignore the autonomy of individuals while exercising their authority.

Healthcare providers’ duty to do no harm (nonmaleficence) can contradict the autonomy of a patient with suicidal ideation. Reporting suicide ideation to members of the healthcare team not providing direct care to a patient complies with the beneficence principle; however, this would breach patient confidentiality. This leads to a dilemma; neither can be chosen without violating the other.

The ethical principle of autonomy calls for respect, dignity, and choice, and therefore a person should not be coerced or manipulated into treatment if they are capable of autonomous decision-making. Taking away a person’s freedom when no crime has been committed is a very serious enterprise. Cases involving a suicidal patient are the classic example of what is considered justified involuntary hospitalization. However, there is ambivalence concerning this, and it is argued by some that the risk of suicide by itself may not be sufficient justification and can increase the risk of suicide following discharge.

Evidence is accumulating about harms inherent in civil commitment. Three arguments include:

Inadequate attention has been given to the harms resulting from the use of coercion and the loss of autonomy.
Inadequate evidence exists that involuntary hospitalization is an effective method to reduce deaths by suicide.
Some patients with suicidal ideation may benefit more from therapeutic interventions that maximize and support autonomy and personal responsibility.
(Borecky et al., 2019; Colack et al., 2021)

Differing Perspectives

There are several different perspectives when approaching the question of what should be done about a patient who has expressed verbally or by action the wish to die. Three such points of view are the libertarian, the communitarian, and the egalitarian-liberal perspectives.

The libertarian perspective is centered on the idea of autonomy and generally rejects involuntary hospitalization because it:

Takes away the person’s freedom
Restricts what the person can do with their body
Prevents the person from protecting property (job, home)
Is a means to manage people who do not adhere to social norms
Coerces and manipulates patients into treatment
Raises financial issues that may affect the patient and/or infringe on the property rights of other citizens (e.g., use of tax dollars)
Does not recognize that suicide is sometimes a rational choice based on competent thought and decision-making skills

The communitarian perspective disregards the person’s autonomy and exclusively considers the community values of the clinician making the decision. It views suicide as morally wrong and offensive to the dominant group, and intervention must take place to prevent it.

The egalitarian-liberal perspective emphasizes the equality of access to resources. This approach states that the government’s role is to protect individual rights and that the right to health is a priority. If the right to health is not protected, then the rights of liberty and autonomy may not be possible. Involuntary hospitalization protects the person from a decision-impairing disease or disorder that puts the patient at risk for self-injury or death, and treatment of said disease or disorder gives the patient the right of health. However, the question remains as to how a mental health professional can know in advance that forcible treatment is justified, especially since there are no objective tests to verify whether or not a decision-impairing disease or disorder may or may not exist (Sandu et al., 2018).