Permitting suicide of competent clients in counseling: legal and moral considerations

State statutes, case law, and professional codes of ethics in the mental health professions typically stress either a duty or the permissibility of disclosing confidential information in order to prevent clients from seriously harming themselves. These sources are intended to address cases where clients are deemed to be suffering from cognitive dysfunction for which paternalistic intervention, including involuntary hospitalization, is considered necessary to prevent self-destructive behavior. The counselor's moral and legal responsibility is less apparent when mentally competent clients desire suicide as release from irremediable suffering due to severe physical illness, and this desire is defensible within these clients' value systems. This paper will explore moral and legal dimensions of a counselor's decision not to intervene in such cases. The concept of permitted suicide will be introduced and defined, and guidelines for its application developed.     

Documenting suicide risk assessments and proportionate clinical actions to improve patient safety and mitigate legal risk

Few clinical practices are as important for simultaneously augmenting patient safety and mitigating legal risk as the judicious evaluation and stratification of a patient's risk for suicide, proportionate clinical actions based thereon taken by the healthcare provider, and contemporaneous documentation of the foregoing. In this article, we draw from our combined decades of multidisciplinary experience as a clinical psychologist, forensic psychiatrist, medical malpractice attorney, and clinical psychology trainee to discuss the documentation of suicide risk assessment and management as a conduit to patient safety and legal risk mitigation. We additionally highlight documentation as a core clinical competency across disciplines and note areas of improvement, such as increased training, to bolster documentation practices.     

一梦成囚犯

项庄村的项成粗通文墨,特别好钻研《周公解梦》一类的迷信书籍。一觉醒来,他先想想梦境,再对照书思考思考,然后决定这天出门做生意上哪方顺当。 这天早起,他一起床,心里就像压上了一块砖     

The epidemiology of suicide and attempted suicide

Since more than one century suicides have been registered in national statistics of death causes. They thus furnish one of the few parameters of psychiatrically relevant behaviour by means of which trends, cohort, age-group and period effects can be studied over longer periods. Since the second half of last century, the suicide rates for Swiss males--similar to those found in England and Wales--show a decrease in consecutive birth cohorts up to males born in the decade 1930-1940, and a continued decline in the total trend until about World War II. From then on the suicide rates of males in consecutive birth cohorts have been slowly increasing in the majority of European and North American countries--but not so in Sweden. Opposite to this, the predominantly low rates for females display little change. Further to the considerable differences between nations and the predominance of suicides committed by females in some Asian countries and Cuba, the changes indicate the significance of cultural and economic environmental factors. Typical period effects are mainly the result of changes in conception and conditions of life. In attempted suicide they proceed in a more sensitive and more rapid way and are about ten times higher. Such a period effect showing increases by about 300% in younger age-groups followed by a decline, attaining its peak about 1976, was ascertained in large cities of the Federal Republic of Germany. By the example of the effects of a television serial, the study of causal processes turning collective environmental factors into individual suicidal behaviour, proved that regularities are effective in learning by a process of modelling. Besides, the epidemiological data give essential hints how to treat suicidal behaviour.     

Endocrinology and suicide

The data accumulated so far suggest several tentative conclusions. First, thyroid and adrenal gland disease unquestionably can produce severe mental disturbances. Most of these are "organic" in nature, but depressive symptoms are common as well. A connection between these diseases and suicide has not been established, however. Research cannot really address this possibility adequately, since these studies are difficult, if not impossible, to do in the postmortem state at this time. Ways should continue to be sought to overcome this problem. Clinically, it seems advisable to treat all depressed, suicidal persons with the same caution, whether they have diseases of these endocrine systems or not. The differences in responsiveness of the thyroid and adrenocortical systems among depressed and perhaps truly suicidal persons are of greater theoretical as well as practical clinical interest. The TRH-TSH test and the DST may not be as specific as once thought. Nonetheless, the abnormalities do occur with regularity in specific subgroups of depressed patients. It is far too early to stop research on the DST or the TRH-TSH test. Clinically, however, it is premature to make important management decisions about suicidal patients based on these test results. At this time, we really have no means of pinpointing the persons who will eventually suicide. The hope that they may someday provide valid data for assessing real suicide potential is there, and clinicians should stay informed in this arena. Until that day comes, though, we must continue to exercise caution regarding our clinical judgments and to live with their uncertainties.     

Cancer and suicide

Mortality rates from suicide and cancer in 1990 in 37 European nations were positively associated.     

Moral development and perceptions of attempted suicide and physician-assisted suicide

In a sample of 115 undergraduates, no association was found between a measure of moral development and the perception of attempted suicides. For the 85 women in the sample, a higher moral development score was associated with less approval of physician-assisted suicide.     

Depression, suicide, and suicide prevention in schizophrenia

Suicide is the single largest cause of premature death among individuals with schizophrenia. Furthermore, epidemiological data indicate that nearly 80% of patients with the diagnosis of schizophrenia will experience a major depressive episode at some time during their lifetime. This report reviews recent findings relative to the risk of suicide in schizophrenia, including data from the Chestnut Lodge longitudinal study of schizophrenia subtypes and symptom domains. Paradoxically, those patients with schizophrenia who are most likely to recover or experience a good outcome are also those at greatest risk for suicide. The reduction of morbidity and mortality in schizophrenia should include depression and suicidality as targets for both psychopharmacological and psychosocial treatment.     

Epilepsy and suicide

Although statistics dealing with the causes of death are often difficult to compare, in some cases they indicate that suicide rates are high among people suffering from seizures. The author considers this critically. At present the number of attempted suicides among this group is at least five times higher than among the average population. The author reports on his own findings, on factors indicating potential suicide victims, and on the possible prevention of suicide, particularly in connection with pharmaceutical treatment.     

Islam and suicide

Suicide and homicide rates of a sample of 72 nations were associated with a cluster of social variables related to economic development but not with a cluster related to the proportion of Islamic adherents.     

Individualism and suicide

In a sample of 19 nations, suicide rates were not associated with nations' estimates of work locus of control, job satisfaction, psychological well-being, physical well-being, or individualism.     

The legal self: executive processes and legal theory

When laws or legal principles mention mental states such as intentions to form a contract, knowledge of risk, or purposely causing a death, what parts of the brain are they speaking about? We argue here that these principles are tacitly directed at our prefrontal executive processes. Our current best theories of consciousness portray it as a workspace in which executive processes operate, but what is important to the law is what is done with the workspace content rather than the content itself. This makes executive processes more important to the law than consciousness, since they are responsible for channelling conscious decision-making into intentions and actions, or inhibiting action. We provide a summary of the current state of our knowledge about executive processes, which consists primarily of information about which portions of the prefrontal lobes perform which executive processes. Then we describe several examples in which legal principles can be understood as tacitly singling out executive processes, including principles regarding defendants' intentions or plans to commit crimes and their awareness that certain facts are the case (for instance, that a gun is loaded), as well as excusatory principles which result in lesser responsibility for those who are juveniles, mentally ill, sleepwalking, hypnotized, or who suffer from psychopathy.     

Argumentation in ethics, legal dogmatics and legal practice

The author adopts a coherentist approach to legal argumentation.Ceteris paribus, the degree of coherence of argumentation depends on answers to such questions as: How many statements belonging to the justification are supported by reasons, that is, not arbitrary?, How profound is the justification, that is, how long are the chains of reasons it contains?, How closely interconnected are the reasons, for example in such a way that the same conclusion follows from various independent reasons?, How relevant are the reasons in the context in question?, etc.A reasonable legal argumentation is a special case of a reasonable moral argumentation. Both contain moral substantive reasons and legal authority reasons. On the other hand, some particularities of legal argumentation must be noticed, as well. Among other things, the lawyers take for granted that legal reasoning is based on valid law and that some sources of law, such as statutes, are binding.There exist various juristic roles and corresponding types of argumentation, e.g., judicial and doctrinal ones. Yet, all kinds of legal argumentation must use weighing and balancing in order to make the law coherent and morally acceptable. Consequently, all general principles and criteria of coherence are applicable to all these types but their weight varies between them.     

Motives for suicide in suicide notes from women and men

Suicide notes written by 16 adult women and 16 men were evaluated by 16 nonprofessional adult judges with regard to love or work problems as suicide motives. Consistent with current theory on gender and suicidal behavior, women and men did not differ in love or work motives.