Suicide and the Law

SUMMARY

The purpose of this chapter is to delineate how mental health professionals can prevent their clients from acting in a suicidal manner while protecting themselves against potential liability when a client attempts or completes suicide. In our increasingly litigious society mental health professionals can apply their understanding about the elements of legal liability in cases involving client suicidal behaviors to structure their services in a manner to meet their responsibility in treating potentially suicidal clients.     

Suicide reduction and prevention: strategies and interventions

This paper focuses on suicide reduction and prevention. It considers what the United Kingdom government and associated bodies such as Department of Health, the National Health Service and Prison Service could do and are considering doing to prevent suicide in Britain. UK suicide statistics for the period 1971 and 1997 are compared and the Highland Health Board suicide prevention strategy for the 1990s is considered. The articles in this symposium are introduced and the recent UK legal cases involving Ms B and Diane Pretty are included.

Counsellors and psychotherapists have always been concerned, to varying degrees, about clients committing or attempting suicide [1]. It is a topic which can trigger much concern and interest with both neophyte and experienced therapists [2]. In the past decade there has been a growth in individual membership of counselling and psychotherapeutic professional bodies with more therapists becoming accredited and/or registered as qualified practitioners. Thus there has been additional pressure on therapists to adhere to professional codes of practice and ethics.To take the correct action and to be seen to take the correct action within client-therapist relationships is now paramount. It could be argued that this has always been the case. However, therapists not working within a professional framework may have had less incentive to act in a professional manner. A proactive approach may be recommended when seeing clients with suicidal ideation and/or intention (Palmer, 1995). In these cases, inaction can sometimes prove fatal so it is incumbent upon the therapist to support and help the client through the difficult period (Curwen, 1997).     

Physician Aid-in-Dying and Suicide Prevention in Psychiatry: A Moral Crisis?

Involuntary psychiatric commitment for suicide prevention and physician aid-in-dying (PAD) in terminal illness combine to create a moral dilemma. If PAD in terminal illness is permissible, it should also be permissible for some who suffer from nonterminal psychiatric illness: suffering provides much of the justification for PAD, and the suffering in mental illness can be as severe as in physical illness. But involuntary psychiatric commitment to prevent suicide suggests that the suffering of persons with mental illness does not justify ending their own lives, ruling out PAD. Since both practices have compelling underlying justifications, the most reasonable accommodation might seem to be to allow PAD for persons with mental illness whose suffering is severe enough to justify self-killing, but prohibit PAD for persons whose suffering is less severe. This compromise, however, would require the articulation of standards by which persons’ mental as well as physical suffering could be evaluated. Doing so would present a serious philosophical challenge.     

Rational suicide and the crisis of terminal illness

Abstract

One of the controversial issues facing counselors in the 1990s is whether or not suicide may be considered a rational choice for clients with terminal illness. This article begins by reviewing the definition of rational suicide and the literature and statistics pertaining to suicide and terminal illness. Then various issues related to rational suicide as a treatment option are addressed, including moral and ethical issues.     

Custodial suicide and class action remedies: Current obstacles and future directions

Custodial suicide is a foundational concern for correctional systems. The incarcerated population is at an increased risk for suicide as compared with people living in the community. Sufficient suicide prevention is a critical component of a constitutionally adequate system of correctional mental health care. The remedial phases of class action litigations have animated improvement in suicide prevention in many correctional systems across the United States. In the current climate, many legal obstacles make it more difficult for plaintiffs to prevail in such cases, but it is expected that advocates will find novel approaches in response to these legal hurdles, such as greater reliance on state law remedies, and will seek to expand the scope of potential actions in emerging areas such as immigration detention. Defendants and courts will, in turn, need to respond to these changes. This article explores the history of relevant litigations, and the legal obstacles currently faced by plaintiffs, as well as future directions the authors consider will likely be taken. Practical issues such as appropriate measurement of improvement in the area of suicide prevention are also explored.     

What Right to Die?

This letter first discusses two meanings of a "right to die." In the popular sense, the term refers to a right to refuse life-sustaining treatment. In the strict sense, the term signifies an affirmative right to obtain death--a right to suicide. The letter then explores the legal implications of a suicide right. This right would extend to competent adults, mature minors, and probably also incompetent persons. Counselors would have to inform clients of the suicide option. Intervention to prevent suicide could trigger civil liability. Suicidal intentions would not justify involuntary commitment. Consent would become a defense to homicide.     

中国体育市场伦理规范的缺损与重构

中国体育市场的法律规范与伦理规范本身具有依存性,中国体育市场现阶段发展主要不是法制缺乏,而是需要重构伦理规范并给法制规范以新的支撑点的问题。     

Would we rather lose our life than lose our self? Lessons from the Dutch debate on euthanasia for patients with dementia

This article reviews the Dutch societal debate on euthanasia/assisted suicide in dementia cases, specifically Alzheimer's disease. It discusses the ethical and practical dilemmas created by euthanasia requests in advance directives and the related inconsistencies in the Dutch legal regulations regarding euthanasia/assisted suicide. After an initial focus on euthanasia in advanced dementia, the actual debate concentrates on making euthanasia/assisted suicide possible in the very early stages of dementia. A review of the few known cases of assisted suicide of people with so-called early dementia raises the question why requests for euthanasia/assisted suicide from patients in the early stage of (late onset) Alzheimer's disease are virtually non-existent. In response to this question two explanations are offered. It is concluded that, in addition to a moral discussion on the limits of anticipatory choices, there is an urgent need to develop research into the patient's perspective with regard to medical treatment and care-giving in dementia, including end-of-life care.     

Assisted Suicide,Suffering and the Meaning of a Life

The ethical problems surrounding voluntary assisted suicide remain formidable, and are unlikely to be resolved in pluralist societies. An examination of historical attitudes to suicide suggests that modernity has inherited a formidable complex of religious and moral attitudes to suicide, whether assisted or not. Advocates usually invoke the ending of intolerable suffering as one justification for euthanasia of this kind. This does not provide an adequate justification by itself, because there are (at least theoretically) methods which would relieve suffering without causing the physical death of the suffering person. Carried to extremes, these methods would finish the life worth living, but leave a being which was technically alive. Such acts, however, would provide no moral escape, since they would create beings without meaning. Arguments seeking to justify ending the lives of others need some grounding in concepts of the meaning of a life. The euthanasia discourse therefore needs to take at least some account of the meaning we construct for our lives and the lives of others.     

Schopenhauer on the ethics of suicide

The concept of death is of special importance in Schopenhauer's metaphysics of appearance and Will. Death for Schopenhauer is the aim and purpose of life, that toward which life is directed, and the denial of the individual will to life. Despite his profound pessimism, Schopenhauer vehemently rejects suicide as an unworthy affirmation of the will to life by those who seek to escape rather than seek nondiscursive knowledge of Will in suffering. The only manner of self-destruction Schopenhauer finds philosophically acceptable is the ascetic saint's death by starvation. Here the individual will to life is so completely mastered as to refuse even the most basic desire for nourishment, and thereby passes into nonexistence in complete renunciation of the individual will. Schopenhauer's attitude toward suicide nevertheless embodies an inconsistency. If, as Schopenhauer believes, the aim of life is death, and death is an unreal aspect of the world as appearance, then there appears to be no justification why the philosopher should not rush headlong into it - not to affirm the will to life in an abject effort to avoid suffering, but in order to fulfill life's purpose by ending it for distinctly philosophical reasons immediately upon arriving at an understanding of the appearance-reality distinction.     

The Moral Foundations of Equipoise and Its Role in International Research

This article reviews the Dutch societal debate on euthanasia/assisted suicide in dementia cases, specifically Alzheimer's disease. It discusses the ethical and practical dilemmas created by euthanasia requests in advance directives and the related inconsistencies in the Dutch legal regulations regarding euthanasia/assisted suicide. After an initial focus on euthanasia in advanced dementia, the actual debate concentrates on making euthanasia/assisted suicide possible in the very early stages of dementia. A review of the few known cases of assisted suicide of people with so-called early dementia raises the question why requests for euthanasia/assisted suicide from patients in the early stage of (late onset) Alzheimer's disease are virtually non-existent. In response to this question two explanations are offered. It is concluded that, in addition to a moral discussion on the limits of anticipatory choices, there is an urgent need to develop research into the patient's perspective with regard to medical treatment and care-giving in dementia, including end-of-life care.     

Legal issues of professional negligence in suicide cases

Suicide is the eleventh leading cause of death, accounting for almost 30,000 deaths each year in the United States. The loss of a patient to suicide is the most feared outcome among mental health professionals, while the fear of litigation and liability after such suicide may be a close second. This article will familiarize mental health professionals with the legal issues of professional negligence in suicide cases. We begin with an introduction to malpractice liability for suicidal patients, followed by an explanation of the essential elements of professional negligence and relevant legal terminology. We then discuss general theories of liability involving suicide, and provide illustrative legal case examples. We conclude with a discussion of risk management procedures that can substantially reduce one's exposure to malpractice liability.     

Laying down one's life for oneself.

Roman Catholicism has long opposed suicide. Although Scripture neither condones nor condemns suicide explicitly, cases in the Bible that are purported to be suicides fall into several different categories, and the Roman Catholic tradition can show why some of these should be considered morally wrong and some should not. While Christian martyrdom is praised, it is not correct to argue that this Christian outlook invites suicide, or that it recommends physician-assisted suicide for altruistic motives. Church Tradition, from its earliest days, has clearly distinguished martyrdom from suicide. The principles of double effect and cooperation, mainstays in Roman Catholic moral theology, enable one to see the moral difference between martyrdom and suicide, and to appreciate why physician-assisted suicide is wrong for both patient and physician.     

A Kantian moral duty for the soon-to-be demented to commit suicide

It has been argued that, on Kantian grounds, pedophiles, rapists and murderers are morally obligated to take their own lives prior to committing a violent action that will end their moral agency. That is, to avoid destroying the agent's moral life by performing a morally suicidal action, the agent, while he still is a moral agent, should end his body's life. Although the cases of dementia and the morally reprehensible are vastly different, this Kantian interpretation might be useful in the debate on the permissibility of suicide for those facing dementia's effects. If moral agents have a duty to act as moral agents, then those who will lose their moral identity as moral agents have an obligation to themselves to end their physical lives prior to losing their dignity as persons.     

Observations on the rejection of physician-assisted suicide: a Roman Catholic perspective.

Roman Catholic moral theology follows a centuries-old tradition of moral reflection. Contemporary Roman Catholic moral theory applies these traditional arguments to the realm of medical ethics, including the issues of active euthanasia and physician-assisted suicide. Unavoidable moral limits on licit medical intervention sometimes require that the moral duty to treat cede to the duty to cease treatment when measures become more harmful than beneficial to the patient. This does not reduce the need for the compassionate use of palliative care in response to suffering. However, it does mean that rather than being excessively committed to maintaining mere biological human life, or actively seeking death, that we learn a sober realism about the limits of human life. Catholic moral analysis examines an act objectively, both in its relation to the agent and as a material event in the world. This allows both the virtuous or vicious intentions of the agent and the effects of the action to be included in its moral evaluation. Thus, Catholic moral analysis is both quasi-deontological and quasi-consequentialist. Objectively, active euthanasia and physician-assisted suicide, as acts of deliberate killing, are seen as repugnant, in that they fail to incarnate a benign inner intention or to form an agent in virtue. Catholic moral theology is extremely skeptical that an act of intending death directly can be consonant with a sincere compassion for the dying, suffering person and views it as a direct negation of the precious gift of human life.     

Intention and Responsibility in Double Effect Cases

I argue that the moral distinction in double effect cases rests on a difference not in intention as traditionally stated in the Doctrine of Double Effect (DDE), but in desire. The traditional DDE has difficulty ensuring that an agent intends the bad effect just in those cases where what he does is morally objectionable. I show firstly that the mental state of a rational agent who is certain that a side-effect will occur satisfies Bratman's criteria for intending that effect. I then clarify the nature of the moral distinction in double effect cases and how it can be used to evaluate the moral blameworthiness of agents rather than the moral status of acts. The agent's blameworthiness is reduced not by his lack of intention but by his desire not to bring about the side-effect, and the 'counterfactual test' can be used to determine whether he desires the effect in acting. In my version, the DDE has its rationale in virtue ethics; it is not liable to abuse as the traditional version is; and it makes more plausible distinctions when applied to standard examples.     

A Kantian Moral Duty for the Soon-to-be Demented to Commit Suicide

It has been argued that, on Kantian grounds, pedophiles, rapists and murderers are morally obligated to take their own lives prior to committing a violent action that will end their moral agency. That is, to avoid destroying the agent's moral life by performing a morally suicidal action, the agent, while he still is a moral agent, should end his body's life. Although the cases of dementia and the morally reprehensible are vastly different, this Kantian interpretation might be useful in the debate on the permissibility of suicide for those facing dementia's effects. If moral agents have a duty to act as moral agents, then those who will lose their moral identity as moral agents have an obligation to themselves to end their physical lives prior to losing their dignity as persons.     

Ethics and Counseling Decisions

Although some behavioral scientists and practitioners contend that man has no genuine moral choices to make, common sense and philosophical reflection ineluctably affirm the moral nature of man. When young people are faced with moral decisions, they often seek the assistance of a counselor. Although such counselors are routinely expected to aid clients in making decisions about their education and their careers, there is considerably less agreement about their responsibility for helping students to make moral choices. The central thesis of this article is that a knowledge of ethical theories, the practical principles which flow from them, and the method of decision-making which they indicate will enable the counselor to assist his clients with their moral problems.     

Being transformed: Delivering a psychotherapeutic group intervention targeting repeat suicide attempts

Clients who make repeat suicide attempts have complex needs, are at high risk of completed suicide and pose a range of challenges for clinicians. Targeted interventions are required. Acceptability, the perceived appropriateness of an intervention, is associated with successful implementation, engagement and effectiveness of interventions. Despite the advantages of group interventions, there is limited research into the acceptability of groups with this population. Using Interpretative Phenomenological Analysis, this paper reports on facilitators’ experiences (n = 9) of the acceptability of a therapeutic group intervention (PISA – a Psychoeducational/psychosocial Intervention for persons who make recurrent Suicide Attempts). Analysis of focus group data revealed how involvement with the intervention profoundly influenced facilitators’ perceptions of and approach to their work with this client group. They embraced the model, developed a deeper appreciation of clients’ resources and became unburdened from sole responsibility for the clients, the therapeutic process and outcomes. PISA provided a model that helped facilitators to work in a focused, compassionate and creative manner as they addressed the central concern of these clients, their suicidal desire, with newly found confidence and eagerness. PISA was experienced as acceptable to facilitators as it was useful to them and deemed appropriate and beneficial to the target population.     

Die straf- und standesrechtliche Bewertung ärztlicher Suizidbeihilfe

In a judgement dated 14 May 2013, the European Court of Human Rights (ECtHR) decided that it constitutes a violation of the rights guaranteed by the European Convention on Human Rights (ECHR) if a national legal system does not explicitly clarify the circumstances under which physician-assisted suicide may be granted to people who are not suffering from an irreversible and life-threatening illness. Although the decision was issued against Switzerland and does not unfold any direct effects on those member states which were not involved in the legal process, the statements given by the court broadly affect the interpretation of the ECHR on the national level. Against this background and with regard to the fact that until the present day the question of the admissibility of assisted suicide has not been exclusively answered, the article takes the verdict of the ECtHR as a reason for analyzing the relevant German regulations. It was found that the provisions of the core areas of criminal law leave no doubt as to the impunity of assisted suicide as long as it is granted to someone who is not limited in the ability to judge although a corresponding clarification by the Federal High Court has not yet been issued. However, the canons of professional ethics turn out to be less clear. As the reform of the Model Code of Conduct (MCC) by the Federal Medical Association in 2011 did not solve the question of the admissibility of assisted suicide in a satisfying manner, many regional medical associations refused to implement the relevant section 16 of the MCC. The resulting inconsistency and insecurity in the legal assessment provide further evidence of the need for a uniform federal regulation that identifies reliable criteria for the evaluation of physician-assisted suicide.