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 patient considering suicide 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)