Respecting Client Autonomy: Facilitated Suicide

Respecting client’s autonomy is the most important principle for a mental health nurse to follow

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The clinical entity of suicide is generally subdivided into the three sub-categories of unassisted suicide, facilitated suicide and assisted suicide. (Pabst Battin, M., 1996). The bioethical model considers each of these entities separately. The first category includes all cases where the individual has made an autonomous decision to end their life without the knowledge or assistance of any other person.

The facilitated suicide is a very specific group where the victim undertakes suicide in a situation where they have been under the care of a healthcare professional who had knowledge of the potential risk and that means of either suicide prevention or intervention were available but either not used or not considered. There is a clear distinction between this group and the next to be considered, as there is not a suggestion that the healthcare professional did anything positive to assist the suicide attempt, but there is an element or suggestion of neglect or failure of duty on the part of the healthcare professional to protect the patient. (Kupfer J 1990).

The assisted suicide is where either a healthcare professional or another person actively assists, either in terms of providing the actual means of death or the knowledge and guidance as to its use, in the death of another. Most arguments aimed at supporting this situation are based on an assumption of rationality and competency on the part of the victim. The majority of such situations, if analysed critically, involve severe pain, disability or occasionally stress, each element has the ability to substantially impair rational thought and decision making. (Salvatore A 2000)

Bioethics is the study of value judgements pertaining to human conduct in the area of biology and medicine. It espouses a number of ethical principles which are central to the field but are overlapping, occasionally contradictory and, in the field of suicide in particular, are frankly capable of producing considerable confusion. (Donnelly, J., 1998)

We shall briefly consider the main principles that are relevant to this consideration.

Perhaps the most central ethical principle to consider is that of autonomy. John Stuart Mill (Mill 1982) produced on of the most celebrated treatises on autonomy, which, taken on face value, allows any individual the right to self-determination of all his actions. In most fields of medical practice the principle of autonomy is considered virtually sacrosanct and explicit personal consent is required for most procedures. (Gillon. R. 1997). The practical difficulty arises when the patient is not “competent” (a legal term – not an ethical one).

The arguments that surround the issue of autonomy in relation to suicide effectively turn on this issue. Those who support the autonomous right to suicide arguing that JS Mill was right, and on the other extreme there are those who oppose it pointing out that anyone who comes to the decision to take their life is, by definition, incompetent (legal definition again) (Coulter A. 2002).

Other principles help us further. The Principle of Beneficence (often referred to as the First Principle of Morality), at its most basic level requires the doing of goodness and of being good. This immediately presents the analyst with a problem because the definition of “goodness” is dependent on both environment and culture. What is considered good in one circumstance may not necessarily be good in another. Critically, beneficence implies that the healthcare professional will have carried out his duties, obligations and responsibilities in a spirit of goodness. (McMillan J 2005)

If we also consider the principle of Non-maleficence. Primum non nocere, which literally means “no malice”. Carrick (P 2000) points to the fact that Hippocrates encapsulated this Principle in his dictum “first do no harm”. In its more modern interpretation, it means that not only must the healthcare professional do no harm to the patient, but, critically in this regard, they must take all necessary steps to see that no harm comes to the patient. (Dimond. B. 1999). The World Health Organisation widens this interpretation to one which includes a duty to try to minimise any harm which is unintended or accidental. (WHO 1996).

There are some circumstances, and these certainly have a bearing on consideration of suicide , where, if a clinician or healthcare professional feels that they cannot do good without the possibility of doing harm, then they should take no action at all. We should note that this is primarily a theorist‘s view and, in the real world it is almost impossible to take any action that does not have the possibility of doing harm to a patient.

In conclusion one can agree that, in general terms, autonomy is indeed an important principle for mental health nurse to follow but, in the case of suicide, it is not the most important principle. Mills felt that autonomy required the exhibition of respect, dignity, and choice with the latter being considered generally the most important.

Healthcare professionals have to have respect for personal rights. Suicide has to be seen (generally) as the outcome of a number of processes which result in psychological debilitation. The extension of autonomy to such individuals facilitates suicide. It is generally accepted that respect for the individual patient in these circumstances is more usually demonstrated by recognising their vulnerability.

It is a common finding that the principles of ethics can be antagonistic. Failure to observe one Principle in order to facilitate another does not render an action necessarily unethical. Beneficence must not be sacrificed for autonomy (Minois, G., 1999)

Beneficence is about caring and not just treatment. Every attempt at intervention is warranted. The adoption of the Principle of Non-maleficence calls for the healthcare professional to do whatever is necessary to protect the patient from harm and for whatever it takes to assure the client’s life. (Rich K et al. 2004)

It is generally a mistake to consider that the ethical requirements and the legal requirements in these circumstances are the same. The law sets a minimum set of standards, ethics requires considerably more.

We could conclude by considering the Socratic maxim which is particularly relevant here “Primum non tacere” (First, do not be silent)


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25.4.06 PDG Word count 1,245