Ethical Dilemma: Attempt Suicide Refuses Rescue
Ethical dilemmas are fascinating and a challenge because one has to come up with a decision, usually regarding two contrasting approaches, both of which have ethical merit. The challenge is great in medicine when life vs death rests on the final decision.
From my now inactive “Bioethics Discussion Pages”, I have reproduced below such a dilemma as presented to my visitors during the period from 1997 through 2004 (the oldest responses are present at the end of the posting). I hope my current blog readers find the responses interesting and hopefully some will add their own comments. ..Maurice.
Attempted Suicide Patient Requesting to Die and Refusing Rescue
The case is that of a 35 year old white single female who was found on her bed stuporous and moaning by her father and mother with whom she lives. There was a note in the room written by her explaining that she had carefully considered her life and what was happening to her and that she wanted to die. There was evidence in the bathroom that she had most likely taken three bottles of different pills including barbiturates. The family immediately called the paramedics and the patient was taken to the nearby hospital emergency room. The physician there was presented with the note and the bottles and since the patient was not fully unconscious began to insert a nasogastric tube to aspirate the contents of the stomach. As he was attempting to get the tube down, the patient became briefly more responsive and cried out that she didn't want the tube, she didn't want any treatment and that she wanted to be left alone and allowed to die. She moaned that she had left a note which said she wanted to die and she meant it. The family arrived in the next few minutes and informed the physician that she had not seemed depressed to them and she had never seen a psychiatrist but the medications were prescribed by her general physician. When told about what she had requested of the physician, the family urged that the doctor continue treatment. The physician realized that if she had consumed the pills in the bottles she would most likely not survive without medical treatment and yet it seemed clear that she did not want any treatment. What should he do next?
The issue is whether the doctor must follow the request of the patient and stop treatment and allow her to die. Does the principle of patient autonomy apply here? Can the physician perform a treatment against the consent of the patient? What is the responsibility of the ER physician in this matter? Must the physician be required to participate in completing a yet uncompleted suicide attempt?
Date: Sun, Mar 28, 2004 1:46 AM From: firstname.lastname@example.org To: DoktorMo@aol.com
Talking as a person who has been to the ER numerous times for overdosing, I can identify with this woman. Unless you have a terminal illness and are very old, I don't think anybody wants to die. I have said I wanted to die and even thought it, but if I really wanted to do it, I would know how to do it right. Anybody who says they want to die, is a bloody fool. She is not in her right mind. I am sorry to say that, but that is from one overdoser to another. The doctor is in the ER for one reason, to treat patients and save lives. He should do his job.
Date: Tue, Jan 20, 2004 8:34 PM From: Seth_Fam@msn.com To: DoktorMo@aol.com
First do no harm is the oath doctors have to abide to. I am confident that the doctor in the ER knows that oath and that he did what was necessary to save the woman's life ether she wants it or not. Obviously she is unable to make decisions for her self regardless of what the note says. I read in an article, about aggressive behavior that every act of violence against others or oneself is a cry for help. This woman committed an extreme act of violence on her self, she needs all the help she can get.
Date: Fri, Mar 1, 2002 11:18 AM From: email@example.com To: DoktorMo@aol.com
Regarding the 35 year old woman who tried to commit suicide and wound up in the ER First of all doctors take an oath to do no harm. There should be hestitation to give her medical care immediately. Our laws dictate that the patient should of had a durable power of attorney for medical care if she was unable to make her own decisions. Or living will. Why didnt the nurses, hospital or doctors contact the doctors who gave her the medications and treated her prior to this event and get their diagnosis? Even if it had to wait until she had received emergency care. Were there any signs of suicidal thoughts with her doctors beforehand? Did they send her for more specialized care? The issue that a lawsuit could remedy the problem is horrible. A lawsuit would do nothing for the woman except make her life more miserable and the lawsuit against the doctors would just make them more likely to not want to work with those kind of situations. Why cant anyone see that proper health care for her in the first place would of been the best plan? Today doctors dont even recognize their own patients, they rely on the patients to diagnosis themselves, they hardly ever have all of the medical records, if a patient doesnt have insurance needed tests are never done and everyone is in such a hurry no matter what the patient has even a basic non emergency patient gets the short end of the stick. And doctors talking to each other about the same patient? HA! Nurses HA! I feel sorry for the woman. Nobody helped her before she got to this point. I feel sorry for the doctor in the ER. He didnt choose suicide for her. And what makes anyone think if you want to kill yourself you know how to do it? It isnt like you get to try it a couple of times to figure it out. In life we can die for the simplest of causes and sometimes even the most extreme causes we still live. I doubt if any 35 year old woman would know the exact dose and combination of medications that would cause her death. Medicine is supposed to heal the patient. The system that is in use today is only reactive and uninformed for alot of people. I say put yourself in the shoes of that young woman. I would of helped her find proper care and a program to pay for it. You can say it was too late for that by the time she made it to the ER and this time yes, but why not repair the system so these things are decreased. Is anyone going to tell her while she is there about her legal rights and how to bypass her parents medical decisions for her? No one ever talks about this until you are in that in between place. And if she had that paperwork in her medical record already did anyone think to call her doctor and check? Those things called Living Wills. Everyone can say it is not my fault, but i say if we know this happens what are we doing to fix it? It is a disgrace to read the nurses who say she should of done it right the first time. They are probably working two shifts for very little pay and have a patient load they cannot bear and it is that way non stop. The system needs that fixed too. And since when have doctors needed to be lawyers? It makes me want to rollover and shout.
Date: Mon, Sep 24 2001 4:28 AM From: firstname.lastname@example.org To: DoktorMo@aol.com
Does the principle of patient autonomy apply here? No the patient is currently incompetent and we do not know if the not was written before or after taking the meds. Also, what was the patient's mental status at the time of writing the note this not an advance directive or DNR and even if it was the patient is not terminal.
Can the physician perform a treatment against the consent of the patient? Yes, because the patient is unable to give consent and the situation is life threatening. Once the patient awakens she can extubate herself if she wants but she better be prepared on being re-intubated.
What is the responsibility of the ER physician in this matter? Follow the standards of practice and resuscitate the patient. If he does any thing else he will find himself in court and will lose.
Must the physician be required to participate in completing a yet uncompleted suicide attempt? No. If your are going to end your life do it right. She should have taken the meds so she would not be found until she was cold and dead.
I am a critical care nurse and we get these patients after the ER saves them and half the time they are psych patients or seeking attention for help. I feel sorry for these persons, 1: because they feel their life is so bad they must end it and 2: because the were unable to carry out their wishes. I have told my colleagues that if they save me after a failed suicide attempt I will never forgive them. Anyway like I said earlier if your going to do it do it right!
Jason D. Nichols, RN, Broken Arrow, OK. 74011, email@example.com
Date: Wed, Sep 5, 2001 2:35 PM From: firstname.lastname@example.org To: DoktorMo@aol.com
I believe that if a person really wants to die that they will do what they know will kill them. They would not attempt suicide in a home, where they could be found, and also I don't believe they would leave a note. As far as the ER Physcian is concerned, I believe he should do everything he could for the patient, because the patient was under the influence of mind alternating drugs. Most attempted suicides are like someone else said, "A cry for help". Men succeed much better that women!
Date: Sat, Mar 24, 2001 1:55 PM From: email@example.com To: DoktorMo@aol.com
What a delimma for the ER physician and the family of this patient. The ER physician, I believe, would be actively assisting in the suicide of this patient if he fails to intervene with all possible life saving measures. This is not a patient who has suffered with a long, terminal illness whose resuscitated will prolong an inevitable death. This young woman, if her life is preserved, may go on to make a full recovery and be productive to society. Such a situation begs the question, "does the sacredness of life override any justification to terminate it, no matter how painful, difficult and hopeless that life may be?"
Date: Sun, Aug 6, 2000 12:16 PM From: Julian@greenwoodwinn.freeserve.co.uk To: DoktorMo@aol.com
As presented the facts appear to be:
1. The patient took 3 bottles of pills 2. She left a note that appears to be coherent in its format and content 3. There is no history of psychiatric illness 4. The patient clearly stated to the doctor that she wished to die
The questions are: Does patient autonomy still persist in these circumstances ?
I would suggest that they do. The patient seems to have very clear objectives and taken the trouble to prepare for the suicide, not least by obtaining 3 bottles of barbituates. This alone indicates a high level of premeditation.
With no history of psychiatric illness there seems to be no grounds for questioning the validity of the patients attempt at suicide.
Should the doctor treat the patient against her will ?
No. Clearly the patient wishes to die. She says so, verbally and in written form. In addition, the 'emergency waiver' cited as a reason for undertaking treatment without consent in the ER appears to be void in this case. The patient is coherent enough to state her objective and to request that the doctor does not intervene. She is refusing consent to treatment.
What is the responsibility of the doctor ?
To treat a patient until or unless the patient demands that treatment stops. Treatment may be undertaken with the consent of family members until or unless the patient is able to make that decision.
In this case, the doctor appears to have undertaken the role fully and completely. But the patient is now demanding that the treatment stop. The responsibility of the doctor is to comply with the wishes of his patient. And there is evidence that the request serious and genuine. There appears to be an element of premeditation (having three bottles of Barbituates) and a note.
Should the doctor participate in the suicide by withholding treatment ?
A far more difficult question to answer but let's try.
Participation suggests that the doctor is DOING something to aid the suicide. By withholding treatment I believe that the doctor is letting the patient's actions run their 'natural' course. The patient has taken the ACTIONS and engineered the circumstances, time, method and explanation of her suicide.
If the parents had not come home the suicide would have been completed and successful.
Participation can be passive, providing a means or a method. Perhaps a question that needs to be explored is 'should a patient with no psychiatric history that we know of have been prescribed Barbituates on at least one but possibly three occasions ?' The actions of the general practitioner require closer examination than that of the ER doctor.
However, in short, I believe the doctor will be doing nothing wrong by withholding treatment, especially as the patient has made that request verbally and (de facto) in writing. In complying with the patients wishes the doctor is providing the highest standard of care and allowing full patient autonomy.
Julian Winn RN MCIM DipM
Date: Wed, May 31, 2000 3:22 AM From: firstname.lastname@example.org To: DoktorMo@aol.com
I believe, there is a simple answer to this situation. If you have ever suffered from any form of depression, whether short-term or long-term, then you should understand how this patient felt. She took pills, and wrote a note explicitly saying, "I do not want to live"! As the doctor insisted on curing her, she reassured him that she did not want to live. What should the doctor do?. . . He should respect her decision for autonomy and don't cure her.
Many will say, "She is just suffering from depression and if he cures her, she can get help and then she would be thankful". Most people who suffer from depression attempt to get help and sometimes it doesn't work. Unless a person walks around dreary everyday then they are not depressed. Look around you, alot of people suffer from depression and if they choose to end their suffering, then let them.
Date: Mon, May 8, 2000 10:47 PM From: email@example.com To: DoktorMo@aol.com
about the question of suicide in the ER:
Having worked on both the ambulance and in the ER for years, I can say confidently that almost 100% of the people who *REALLY* want to die, actually do. In other words, all the "calls" that never make it to the ER (successful suicides.... OD's, hangings, GSW's, etc.).
Obviously you can't stand around and let someone die, even if they want it. To do medicine is to preserve life. Now I *realize* there are instances in which "death is prolonged" rather than "life preserved." These cases are most commonly seen in the preservation of brain-dead people. (This is just an example). But in the case of a suicide, look at it this way: If you "betray" the patient by "saving" him, he can always "do it right" the next time, if he is so hell-bent upon dying. In other words, what he needs is help, not death.
Bernard Jain, firstname.lastname@example.org, Applying to med. school.
Date: Tue, Apr 25, 2000 11:28 AM From: email@example.com To: DoktorMo@aol.com
I am intrigued by your case study. I was surfing the Web to see if there was materials on dealing with suicidal patients in the ER when I happened upon your Web site. The situation that has been brought to my attention in very similar to the case you present--but with some very interesting differences. In the situation brought to my attention, the patient is a woman in her 50's. Rather than being found after taking an overdose, she herself called 911. When brought into the ER she was clutching a document which directed the physicians to do nothing and to let her die. The document--written by her two years previously--was signed by two witnesses and notarized. The patient had been in the ER a number of times previously beacuse of suicide attempts. When her family arrived, they verified that she did not want anything done; and they indicated that they were in agreement. The situation left the care providers in a difficult position. They wanted to respect her decision about no treatment. And, from her previous trips to the ER, her decision not only about no treatment but about suicide seemed to be very clear. At the same time, the care providers felt obligated by their profession to respond to her. The institution where this occurred is now in the process of writing a policy--or at least some guidelines--should another similar circumstance arise.
I would be interested in getting copies of any such policies or guidelines that others have developed. Please e-mail them to me at firstname.lastname@example.org
Date: Thu, Mar 9, 2000 11:40 AM From: CCCOLIB@inetmail.att.net To: DoktorMo@aol.com
In re the patient who attempted suicide who tries to refuse treatment:
Suicide tends to be an impulsive act. Poisoning suicides also tend to have a component of the "gesture" in them. The individual acts impulsively and dramatically because it seems like a good idea at the time. These impulses also pass. As this patient may still be in the throes of this impulse, I am unwilling to let her do it.
I also believe that though autonomy is a good, it is not an absolute good. I think the principles of benificence and paternalism have their place in medicine, and the ED is one of them. While patient autonomy cannot be ignored, it is of lesser importance in the ED than in the office. Also, having stipulated that this patient has no underlying medical problems, if she recovers, is treated, and still wishes to commit suicide, she can certainly do so later. As a pathologist I know that suicide is absurdly easy if one is determined, even in an instutional environment, so we're not denying her that option later.
Finally, I think it is unfair to the medical personel to force them into an act of ommission in this setting. As I said, if one is truly determined one can slip oneself under a bus or hang oneself even while bedridden.
Date: Sat, Dec 25, 1999 5:30 PM From: email@example.com To: DoktorMo@aol.com
Hello, I am in a quandry simularly to this in the long term care facility I work in. Two major factors intersect here: one, as a social worker, harm to self and others would make it necessary to intervene. Secondly, the lack of medical issues, and primarily mood/depression signs and symtoms makes me question very seriously the persons ability to reasonably make the decsion she was choosing. Personally, if someone is 95, facing terminal diagnosis and has requested a natural death to occur, I would respect that. A teenager, with depression, hopelessness, and an obvious call for help, would most likely recieve the same response. Legally, "Patient wish supersedes directives or powers of attorney." Where was she a patient? Has she been deemed competent? Past behavior, choices? How is she able to cope
I am using my families e-mail address below. My name is Laurinda. Please feel free to mail them if you think this warrents further discussion. Thank you very much. [Moderator's Note: Also write to this website] L.J. Plank, MSG, LSW Ethics Chair Dimbulbz@earthlink.net
Date: Tue, Oct 26, 1999 4:22 AM From: firstname.lastname@example.org To: DoktorMo@aol.com
In our society, we assume people want to live. In some situations, death may be a rationally defensible option when weighed against the alternative state of living, such as when a person suffers from chronic and severe pain from which no modern therapies can provide relief. We must also assume, however, that persons experiencing such pain may be so influenced by there condition that they may not have ratioanlly considered other options and/or they don't have the emotional or mental strength to seek help on their own. Therefore, in situations like the one presented where there is evidence that the woman has not sought help nor has been provided help from her family, all the potential options available to her other that suicide have not been explored. This suicide is obviously a option of last repsort, she should be treated against her will so she may be recover and seek and/or be provided help.
Wow, was that a cold analysis, don't you think? Our intuitions want to say, "hey, look, shes really depressed, treat her now and get her some help." But in our day and age, we must ratioanlly defend those assumptions made by our gut feelings because others WILL question their validity. Plus, its a good spiritual exercise in that by challenging our intuitions it forces us to articulate those everday values by which we live. Thats my two cents I suppose, thanks for reading.
Sincerely, Todd Ludwig, M.A.
Date: Mon, Oct 18, 1999 1:16 PM From: email@example.com To: DoktorMo@aol.com
I am a firm believer in RATIONAL suicide. I would place the woman under "observation" for a DEFINITE period of time, treat her with GOOD anti-depressants and psychotherapy, and even if she still wanted to kill herself, I would release her ----- after urging her to continue therapy (shows compassion, etc.). I WOULD NOT HOSPITALIZE HER UNDER ANY CIRCUMSTANCES!
Date: Thu, Sep 30, 1999 5:02 PM From: Hlfenton1@aol.com To: DoktorMo@aol.com
Even though she left a note wishing to end her life, and there had been no depression noted, I think someting is still missing psychiatrically. The physician should treat and reffer for psychiatric counseling to find the true meaning of "why" this was done. It would be interesting to find out after 1 year treatment if the young woman felt the same way.
Date: Sat, Jun 5, 1999 12:59 PM From: firstname.lastname@example.org To: DoktorMo@aol.com
The doctor most definitely has to complete treatment. Doesn't a doctor promise in the Hippocratic Oath , "to please no one will I prescribe a deadly drug nor give advice that may cause his death". It is the doctor's duty to complete treatment, they were trained to save lives, not watch them slip away.
Date: Sun, May 16, 1999 9:18 PM From: email@example.com To: DoktorMo@aol.com
In this case, it would seem to me that the ER doctor's ethical position is clear. He must treat her, against her wishes. There are limits to patient autonomy, religious, moral nd legal. Suicide is prohibited by all religions I know of (with the possible exception of Shinto, which permitted harakiri under certain circumstances in the past). The state has an interest in the existence of its subjects and most jurisdictions in the worlr consider suicide a crime (even though suicide attempts are almost never punished). As was recently decided in one court in the trial of "Dr. Death", assisting in suicide is considered illegal. Morally, you must consider the person; we are told this woman was never depressed in the past (to her parents; knowledge) and appeared to function normallly until the date of her sttempt. This was therefore a sudden, rash decision and she might have changed her opinion one day or week or a month later, if she were rescued. Furthermore, a physician's duty is to save lives and to prevent an avoidable death.
Hans G. Engel, M.D.
Date: Wed, Apr 28, 1999 8:20 AM From: firstname.lastname@example.org To: DoktorMo@aol.com
She made her wishes known - she is an adult and has stated her wishes very clearly. Her wishes should be followed - not those of her parents.
Date: Fri, Feb 19, 1999 10:57 AM From: TWOCNTPLN@aol.com To: DoktorMo@aol.com
The case is that of a 35-year-old white single female who was found on her bed stuporous and moaning by her father and mother with whom she lives. There was a note in the room written by her explaining that she had carefully considered her life and what was happening to her and that she wanted to die. There was evidence in the bathroom that she had most likely taken three bottles of different pills including barbiturates. The family immediately called the paramedics and the patient was taken to the nearby hospital emergency room. The physician there was presented with the note and the bottles and since the patient was not fully unconscious began to insert a nasogastric tube to aspirate the contents of the stomach. As he was attempting to get the tube down, the patient became briefly more responsive and cried out that she didn't want the tube, she didn't want any treatment and that she wanted to be left alone and allowed to die. She moaned that she had left a note which said she wanted to die and she meant it. The family arrived in the next few minutes and informed the physician that she had not seemed depressed to them and she had never seen a psychiatrist but the medications were prescribed by her general physician. When told about what she had requested of the physician, the family urged that the doctor continue treatment. Given what pills were consumed, she will most likely not survive without medical treatment.
Should the physician follow the request of the patient and stop treatment and allow her to die, i.e. must the physician be required to participate in completing a yet uncompleted suicide attempt?
The Goals of Medicine
Promotion of Health
Treating the patient for overdue will promote patient's health. In fact, patient likely will die without treatment.
Prevention of Disease
Treating the patient will not prevent disease, but it will cause the dis-ease of patient's continued existence, given that she does not want to live. (It should be noted that from a medical standpoint, it would prevent dis-ease associated with death via overdose.
Relief of Symptoms/Pain/Suffering
Treating patient will relieve patient's pain and suffering only insofar as she has been made uncomfortable by her suicide attempt. Treating patient will, arguably, increase her pain and suffering insofar as patient believes that continuing her life will continue her pain and suffering.
Cure of Disease
Treatment of patient will cure disease (disease not being an illness, but impending death from overdose).
Improvement of Functional Status/ Maintenance of Functional Status
Treatment will greatly improve her functional status insofar as without treatment patient will die. Treatment will (or may) allow patient to return to life.
Prevention of Untimely Death
Treatment will prevent an untimely death. Although I will discuss issues regarding patient's preferences below, clearly, from her family's eyes, the death would be untimely. Likewise, I believe that society would generally feel that a 35-year old has likely not accomplished what she would have hoped for at this stage in life and, thus, the death is untimely. (I note that the fact that she is attempting suicide clearly indicates that she, too, feels that she did not accomplish her goals, or at least did not attain a certain level or she probably would not want to kill herself).
Education and Counseling of Patient
This is not really applicable. If treatment is forgone, there is certainly no time to educate the patient. If treatment is provided, patient will likely undergo some psychiatric counseling to determine why she wishes to end her life. Insofar as the issue of continuing treatment, however, there is no real place for education/counseling - they're only applicable to the outcomes (including education/counseling of the parents if treatment is not provided and patient dies.
Avoiding Harm to Patient
From a strictly medical perspective, treating the patient will avoid the greatest harm there is, death. From an ethical standpoint, that is, from a standpoint of patient preferences, quality of life, etc. continued life would be considered, at least from patient's perspective at this particular point in time, a harm to this patient.
The Principle of Proportionality is fairly clear. From a strictly medical perspective, the Goals of Medicine (as opposed to medical goals of the patient) are ultimately the goal of continued life in a physically healthy person. Thus the Principle of Proportionality would dictate that treatment be provided.
This provides an interesting matter. Here, we've got a patient who indicates very clearly (she has attempted suicide) that she prefers death to life. In addition to the act of suicide, she has written a note that states that she has carefully considered her life, and has chosen not to continue living. Finally, she regains some consciousness during her admission to the Emergency Room and states that she doesn't want treatment, that she left a note and that she wants to die. This evidence makes it clear that patient wants to die.
We must, however, ask ourselves whether or not she is competent in making her decision for forego life-sustaining treatment. Her parents have indicated that they did not believe that patient had been depressed. This point argues both ways. In one sense, the fact that she appeared to be lucid and without emotional distress can indicate that her state of mind was clear and that she was competent. However, the fact that her parents apparently failed to recognize that she is obviously depressed (I'm not aware of any happy people who attempt suicide) indicates either: 1) her parents have no real input as to patient's state of being or competence, since it is clear that they could not recognize emotional problems with patient; or 2) patient was competent in her daily life activities, but we cannot determine her competency in her private matters (since they were not revealed by patient to her family).
We also (and unfortunately we do not have any additional information here) do not know whether patient actually undertook a careful consideration of her life and whether her decision was competent that she believes death to be a better state of being. Her note states that she made careful consideration, but a simple statement that she did does not provide any information about her reasoning, analysis, etc. Perhaps her "careful consideration" was based upon a mistaken belief about her life or situation. Perhaps her "careful consideration" was based on a delusional psychotic episode, thus making an informed decision impossible. Thus, we have no real evidence of patient's ability to make a competent decision on this matter.
Quality of Life
Quality of Life issues include patient autonomy. If the treatment to save her life is commenced, patient's autonomy will be wholly ignored. Society does not have a problem with, and in fact supports, an individual's decision to terminate life-sustaining treatment. This is contingent upon our view of patient autonomy. We will see below that this situation differs from termination of life sustaining treatment in some ways, but the principal behind patient autonomy and patient's right to make medical decisions remains.
Quality of Life also includes the physician-patient relationship. Physician's paternalistic actions can irreparably harm this relationship, not only between patient and physician in this case, but also in all her future dealings with physicians.
Family perspectives are clear. Patient's family want patient to live, and thus, support treatment.
Physician's perspectives are not stated herein, but it is presumed that health care providers would prefer to see that 35 year-old patients (who are otherwise physically healthy) capable of full recovery are treated. This is supported by the Goals of Medicine.
Public Policy perspectives are perhaps the most interesting. While it is true that public policy allows for the withdraw of life sustaining treatment, it is accepted that such withdraw is acceptable for patients in which death is imminent. Although patient's death is imminent, her approaching death is not the result of disease or accident beyond her control, but rather due to self-inflicted harm. Given that we cannot determine her mental capacity to have made this decision, we cannot allow patient to die. Suicide is often, according to psychiatrists/psychologists, a cry for help. Given this, public policy would seem to dictate that patient be treated. This will allow for patient to obtain necessary counseling to determine her reasons for suicide, and whether, in fact, she actually prefers life, but needs to deal with various issues in her life. It must be admitted that such treatment is an affront to patient's autonomy, but given the overpowering reasons stated above, patient's autonomy is worth sacrificing in these situations.
Financial perspectives are not relevant.
Cultural/religious beliefs can be, however we have no information regarding patient's religious beliefs. Some religions would consider suicide unacceptable and would also demand treatment be given.
Legal factors play a small role. Suicide is not illegal, however many states do not allow for physician-assisted suicide. In fact, only Oregon permits it. The legal question here is whether the physician would be assisting a suicide if he fails to provide treatment. I think it could be successfully argued that physician did not assist suicide, even if he let patient die. Physician did nothing to put patient in condition she is in (he did not supply drugs or any other medical intervention). There may, however, be an action for negligence or failure to treat if he does not treat patient, but these a different from assisting suicide.
On the continuum, the goals of medicine, principle of proportionality, quality of life and contextual features dictate that treatment be provided. Patient perspectives are not clear here since we cannot determine patient's state of mind or competence to refuse treatment in this matter. The decision to treat falls at absolute duty.
Daniel Seltzer, JD, Student, MA HealthCare Ethics, Rush University, Chicago, IL
Date: Wed, Dec 2, 1998 1:56 PM From: email@example.com To: DoktorMo@aol.com
As a practicing Emerg Doc, I don't practice with Socrates in mind very often, but I think there is not much of dilemma here. I treat her. If she gets lives, and wants to kill herself later, she will have the opportunity I'm sure. If she gets lives and and her depression is treated, she and her family may be thankful.
If I let her die, she will not have the opportunity to have her depression get better. If I let her die, (against the wishes of her family no less) I'm looking at many hours of talking with lawyers.
If I treat her, it is the unusual lawyer which would take the case ("so the doctor treated you and you didn't die and you want to sue him?")
Sorry for making it seem so simple, but to me it is. And yes I have treated people in this scenario several times in my career, and I have always treated them.
Date: Fri, Oct 30, 1998 5:32 PM From: ShArPeTuRn@aol.com To: DoktorMo@aol.com
I think that if someone is not in the right state of mind. Which usually when someone is sucidal they want to die. The doctor should do all he can to save the person, unless when the get out of the sucidal "room/stage" they will not be able to fuction like normal.
Date: Tue, Oct 27, 1998 4:33 PM From: XxU1N2C3xX@aol.com To: DoktorMo@aol.com
Suicide is more of a disease process rather then a rational decision. It is linked to low serotonin levels in the brain. The deficiency is caused by high levels of stress and psychological pain associated with chronic depression in some people and acute depression in others. In the case which is presented the family members of the 35 year lady said that Òshe did not look depressedÓ; but maybe she was and she just didnÕt show it. The patient wanted to die from what it said in the letter and even when the doctor tried to insert a nasogastric tube into the patient and the patient began to cry out that she did not want the tube and that she didnÕt want any treatment and that she wanted to be left alone and allowed to die. The physician cannot perform a treatment against the consent of the patient. The lady didnÕt want the tube and so the physician cannot give it to her. The patient has rights not to want something. The autonomy of the patient does not apply because, she can function independently with out the aid of the doctor but she governs her body herself and so she can tell the docter she does not want the tube and just wants to die. The ER physician is just like the other physician (doctor) they are not allowed do stuff without the consent of the patient and so they donÕt do anything. The physician is not required to participate in completing a uncompleted suicide if he or she does not wish to because the patient has taken his life in his own hand and can do what ever he or she wants to do and the 35 year old lady can do what she wishes because she is old enough to do so and the doctor can help if he wishes too. So the suicide patient can do what he or she wishes because they have the right to get help or not and the physician can not do anything. I think if the patient request to die then let the patient die.
From: Aarti Patel
Date: Wed, Sep 23, 1998 12:26 PM From: firstname.lastname@example.org To: DoktorMo@aol.com
I generally believe individual has the right to accept or refuse treatment. Even when decision wile result in death. However, in this case, I believe the ER physician must press ahead with resesutation efforts for several reasons. First ,I have doubt the patient is competent to direct her own treatment following the ingestion of, presumably, a large quantify of barbiturates and other unknown drugs. I believe one must assume the other drugs are depressants and may cloud the patients judgment- at that moment.
If the patient had a long history of depression, therapy, etc. then one may feel justified in honoring her written note. In the absence of such evidence, treatment is permissible.
Charles M Davis, MD
Date: Sun, Jun 7, 1998 7:12 PM From: email@example.com To: DoktorMo@aol.com
I am learning how to use the Internet and chanced on to this dilemma. the answer may be found in the Socratic dialogues Phaedo and Crito. In Phaedo Socrates argues that man's relationship to God is that of a slave or oxen to the master and just as the latter have no right to put themselves out of the way so man cannot. In Crito, he says that since he enjoyed the benefits of the state he must bear the burdens, so if life was worth living when it was painless then pain must be borne, too, because that is justice and justice precedes one's self interest and hence it is in the ER Dr's duty to engage in a Socratic dialogue with the patient after rescuing.
Date: Thu, Apr 30, 1998 1:08 PM From: N.DENHAM@newman.ac.uk To: DoktorMo@aol.com
The doctor should save this woman's life. After she has had counselling and when she realises that she has too much too loose, she may thank him for it. It's up to you though, can you really live with yourself if you assist her with her suicide??
Date: Sat, Feb 23, 1998 6:40 PM From: Tshcma@aol.com To: DoktorMo@aol.com
There is mounting research that suicide is a *disease process * rather than a rational decision. It has been linked to low serotonin levels in the brain. This chemical deficiency is caused by extraordinary levels of stress and psychological pain associated with chronic depression in some people and acute depression in others. Suicide Survivors (parents, spouses, siblings, children, etc. of someone who has completed suicide) and clinicians both report that the deceased often cited unbearable pain as the reason for wanting to die. Research on chronic intractable pain indicates that sufferers experience diminished self-esteem and a loss of control. This appears to occur with severe emotional pain ("psychache") as well. Suicidal individuals become trapped in a spiral of psychological stress which overcomes their physiological defenses. Suicidal individuals experience traumatic stress disorder where the trauma is confronting their wish to die. They want to die to *end their pain * not necessarily their lives. Their pain is temporary as is the transient chemical deficiency that makes them vulnerable. Their pain like all pain can be treated and ameliorated. Medications like Paxil, Zoloft, and other antidepressants can help, but take time to reach clinical levels. People no more want to die of suicide than they want to die of HIV or cancer. Applying the principle of autonomy to cases of suicidal individuals is inappropriate and unpardonable because of their temporary diminished capacity. Many completed suicides are the result according self-determination to individuals who are unable to act otherwise because of the nature of their condition. Doing so without meaningful intervention with their pain is unethical and negligent, and, in effect, assisted suicide.
Date: Sun, Nov 23, 1997 6:02 PM From: MRock2915@aol.com To: DoktorMo@aol.com
The principle of patient autonomy does and doesnÕt apply here. It doesnÕt apply because the woman really isnÕt a patient, because she never wanted or agreed to treatment and that is the definition of a patient. It does apply because the woman, may not be fully competent at the hospital, but she was fully competent when she contemplated suicide and wrote the letter and decided to end her life. The woman made a fully competent choice and if no one found her before the pills took their effect, she wouldÕve gotten her wish and died. The doctor is obligated to follow the wishes of the patient, I think, because she is over eighteen and old enough to make her own decisions, and wrote the letter when she was competent. The doctor should allow her to die if that is what she wants.
The physician can only perform a treatment against the consent of a patient when the patient is under eighteen and/or has been incompetent their whole life. This woman is neither of these. She made her decision before she became unconscious and incompetent, so her wishes should be respected. The parents saying that she didnÕt seem depressed or anything shouldnÕt matter because they really donÕt know what was going on in their daughters life or how she was feeling. There are things that happened that her parents most likely didnÕt know about that made her depressed. The patient said in the note that she thought about everything and made her decision, it wasnÕt like it was some spur of the moment think.
I am really not sure what the responsibility of the ER physician is in this matter. The people in the ER are trained to rescue people who were in violent accidents and thing like that. The ER has been faced with overdoses on drugs before, but people who didnÕt overdose on purpose. The patient overdosed on purpose with hopes of ending her life. The ER physicians should just let her die. If the doctors try to and successfully save her and she really wanted to die, she will try again and their work would be for nothing.
The physician is not required to participate in any kind of suicide. A physician should be required to follow the wishes of the patient, because she made the decision to die. The doctor wouldnÕt be participating in her suicide, but just not treating a person who didnÕt want to be a patient in the first place.
I think that the woman should be able to die because that is what she wanted. She had many chances to stop what she was doing and live, but she did not want that. It is a uncomfortable situation because I can understand how parents wouldnÕt want to loose their child, and a doctor wouldnÕt want to loose a patient, but the woman chose to end her life. They should respect her wishes.
Date: Wed, Oct 8, 1997 3:33PM From: Babyblu953@aol.com To: DoktorMo@aol.com
I think if the 35 year old woman was in her right mind when she was saying in the emergency room that she wanted to die, then that's her choice, it's her body and she can do what she wants with it. But, if she is taking some pills that she has some kind of weird side effects to, then she wouldn't be in the right state of mind, and she'd have no idea of what she was talking about and should be further investigated. Also, taking to some consideration for her family, maybe they didn't see the hurt inside their relative, if there were any. There are a lot of issues involved in this decision, but it is right to go with what the 35 year old says if in the right state of mind, it's her body and she knows what she wants to do with it.
Date: Thu, Oct 2, 1997 3:00 PM From: firstname.lastname@example.org To: DoktorMo@aol.com
I am not the doctor faced with this problem but surely he must continue treatment. It is my understanding that in most places assisting in a suicide is against the law. Refusal of treatment in most hospitals is accepted only after certain procedures are followed, one of which is assessment of capacity. Any 35 year old who truly wants to die would not choose a bedroom in her parent's house unless the parents were on an extended vacation and there was no chance of them walking in to stop the process. In my opinion it was a cry for help and, possibly, an attempt to punish her parents, for she must have known they would find her body. A true attempt would involve checking into a hotel mid-afternoon and let a member of the staff find her the next morning when it would be too late to do anything.
Date: Tue, Jul 15, 1997 5:53 AM From: Nrse4morph@aol.com To: DoktorMo@aol.com
There is no dilemma here. In every contry that allows assisted suicide there is a process for implementing the wishes of the patient. It is not something that is allowed on a casual basis. I have a problem with the case as stated, although I do agree with an earlier comment, that she might not have in fact taken a lethal dose. With few exceptions, suicides who are truly serious about dying do not get found until they are either dead, or beyond rescue. This does not include those individuals who are, even temporarily, incompetent, and therefore unable to plan for their possible discovery. These individuals since they are not mentaly competent are not able to refuse rescue. If an individual wishes to commit suicide, an option I personaly find distastefull at this point in my life, then they should do so with a full awareness of the consquences of their actions to society, their family, and personaly. As with many other choices we make, it should not be done lightly As to the ER Doctor I'll hold her head still while you put it down.
Chuck Masters RN email@example.com
Date: Thu, Apr 10, 1997 3:33 AM From: firstname.lastname@example.org (John Gregor) To: DoktorMo@aol.com
Even if this scenario were to take place in a society where providing suicide-on-demand was legal, I believe that the ER physician would be compelled to make a best effort to save the patient. The largest concern that I have with stopping treatment is that the physician cannot be sure that the patient has consumed a lethal dose of medication. The patient may have only consumed enough to guarantee profound liver, kidney, or brain damage. The patient may also vomit before a lethal dose has been absorbed. Either could lead to the patient surviving, but in a very incapacitated state and exposes the physician to great liability. So, in reality, the question cannot be whether to treat or just stand by helplessly. If those are the only two options, the physician must intervene and treat the overdose. The question should be which active role the physician will take. If the physician were to decide that the patient was entitled to her wish to die, the physicial should administer a lethal IV dose of KCl, phenobarb, or other agent that guarantees a quick, painless death. I don't believe, however, that an ER physician can or should be placed in this position. He or she has too little information at hand. Without a psych consult the physician cannot judge whether or not the patient made an informed and rational choice. Certainly, the request from a barely conscious patient in the ER cannot be taken as consent. While I support the right to commit suicide, I think a proceedure must be established to eliminate the problems like in this example. There must be a psych consult. There must be a physician of record in charge of the case who prescribes and administers the lethal meds. There has to be some legal document stating the intention to die. There must be some sort of counsel/advocate/next-of-kin/etc. present who has been granted the legal authority to refuse treatment (or request treatment that hastens death) on the behalf of the patient. Etc. Without such a procedure in place, you wind up with a jumbled mess where family, EMS, and doctors are put in a situation where the only reasonable, legal action is to attempt to save the patient.
Thanks for an interesting question.
Date: Wed, Apr 9, 1997 10:00 AM From: email@example.com (AMBER BORCHARDT) To: DoktorMo@aol.com
This is a very difficult topic to discuss because there are so many different viewpoints. I believe that God put each one of us on this earth for a reason and when He thinks his plan has been carried out, HE will take the life He has given us. I think the decision should be made by each individual hospital whether or not to try to keep and attempted suicide patient alive or not.
Amber E. Borchardt
Date: Fri, Apr 4, 1997 4:13 PM From: firstname.lastname@example.org (GERALD LARCHE) To: DoktorMo@aol.com
It is a surprising but interesting problem. My opinion is that we should consider the general duty of society and of physicians; we may consider as a philosophical opinion that everyone is free to suicide; but this will cannot be considered as an objection against any rescue. Mutual aid is one of the greatest purposes of living in society. We may also consider as evident that despair is generally the cause of suicides. Somebody who is desperate should be considered as needing some help to live not to die. So, I think that letting the patient die should be considered as a criminal act.(In France it could be punished with a five-year prison sentence and a $ 100,000 fine). If you admit such a freedom, you should also consider all the laws that protect people against themselves or accidents as immoral because anybody should be free for instance to die in a car accident without driving-belt, or to be crushed by a car. Saving people is a duty. May I say that if I had respected her will, I should have let die 13 years ago the girl who became my wife and that obviously, she desired to die because of problems that she overcame. So there is a difference between free will and pathological desire and you can consider that suicide is a pathological desire. "The free man does not think at all to death, and his wisdom is a meditation not on death, but on life". SPINOZA Ethics, book 4, proposition 67; he also writes that when one suicides, one is defeated by external causes and because of one's powerlessness. So, if the will of suiciding people should be obeyed, we should consider that as a moral decline not as a proof of respect of autonomy.
Gerald Larche, teacher of philosophy, Paris. email@example.com
Date: Thu, Apr 3, 1997 8:52 AM From: rvisser@REX.RE.uokhsc.edu (rvisser) To: DoktorMo@aol.com
DoktorMo, I am a senior nursing student at the University of Oklahoma. I recently read your article concerning the ethical dilema faced by Doctor K., and feel very strongly that the physician should have done all that was within his power to save the life of this 35 yo female. It is my understanding that it is the duty of all health care members to do all that is within their scope of practice to prevent death. The exceptions to this include an advanced directive. There is a legal contract that must be signed by the patient and a witness if the patient desires to refuse life-saving procedures. If there is no evidence of this, the physician must do all that is within his/her power to save the patients life. It would be easier to say that because this woman wants to die, that we can all stand back and watch. The legality portion of this ethical dilemma leads me to the conclusion that the Doctor K. must perform the life-saving procedures.
Date: Thu, Mar 27, 1997 8:38 PM From: STA2560@edgar.k12.wi.us (SONNENTAG, STACY) To: DoktorMo@aol.com
This topic is just like Dr. K. he wanted to help people die the way they wanted to die. It is just like saying that if you are 80 years old and your husband/wife would like to die now because he/she doesn't want to die in pain, and they would like you to help them by doing something. So you the lawful other that you are decide to help your wife/husband out. Yet if the law would find out about you trying to kill your other they would arrest you for murder. Even though you were told to do what you did. Dr.'s are told to try and save everyone who comes to their attention. If they didn't they would be commiting murder. Even if a person that could have killed his family comes in with wounds, he still has to help him the best way he can. I believe that the doctor should have done everything he can to help the girl live. After that if she tries to kill herself again it won't be the doctors door that the police are knocking at because he tried to save her life. If he would have respected her wishes, he could be out of a job. I am only 16 years old, but this is my opinion. I don't agree with Elliot L. Goldman either. M.D or not!
Stacy Sonnentag, Student
Date: Tue, Mar 25, 1997 9:05 AM From: firstname.lastname@example.org (Eric S. Fought) To: DoktorMo@aol.com
This is a very interesting case because there is no visible illness that would justify a lack of support. The fine line comes into play when we discuss suicide and it's justification. Is it ever justified? If we believe that suicide is justified in cases of serious illness, (I don't) what about cases like this one. Soon people suffering from indigestion will request to die if they feel their life isn't worth living. A psychiatric consultation is needed in this case, following treatment. The role of the physician in this case is to protect the life of this patient who needs help.
Eric S. Fought
Date: Sat, Feb 15, 1997 10:41 AM From: email@example.com (ELLIOT L GOLDMAN, M.D.) To: DoktorMo@aol.com
Clearly a conundrum without approved guidelines. However, the physician should attempt to save the patient, then establish whether or not depression is responsible for her behavior. Psychiatric consultation would be helpful. If depression was not responsible, the principle of Patient Autonomy would apply thereafter. He would have to withold treatment if she returned the following day with another overdose!
Elliot L. Goldman, M.D. firstname.lastname@example.org