The role of substituted judgment in the aftermath of a suicide attempt

Journal of Clinical Ethics

Volumn 18, Issue 2, 2007, Pages 111-118

  Macauley, Robert C ^a  

^a UNIVERSITY OF VERMONT COLLEGE OF MEDICINE   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

AGED; ARTICLE; CASE REPORT; CUSTODY; DECISION MAKING; ETHICS; HUMAN; MALE; PSYCHOLOGICAL ASPECT; SUICIDE ATTEMPT; TREATMENT REFUSAL;

AGED; DECISION MAKING; HUMANS; JUDGMENT; MALE; PROXY; SUICIDE, ATTEMPTED; TREATMENT REFUSAL;

EID: 34548441963     PISSN: 10467890     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (22)

1. "The principle of patient autonomy requires that physicians respect the decision to forego life-sustaining treatment of a patient who possesses decision-making capacity." Code of Medical Ethics of the American Medical Association (Chicago, Ill.: American Medical Association Press, 2006), 75.
2. Compare with In re Quinlan, 355 A.2d 647 (N.J. 1976).
3. T.L. Beauchamp and J.F. Childress, Principles of Biomedical Ethics, 5th ed. (New York, N.Y.: Oxford University Press, 2001), 98-104.
4. "There is a prevalent (and probably sound) view that a suicide attempt allows a presumption of psychiatric illness and that intervention over the patient's objection is justified." J. Spike, "Physicians' Responsibilities in the Care of Suicidal Patients: Three Case Studies," The Journal of Clinical Ethics 9, no. 3 (Fall 1998): 311.
5. In purely legal terms, there is also the question of whether advance directives apply to situations of self-inflicted injury. One article asserts: "Advance directives ... are considered to be legally binding when a patient presents with symptoms from a naturally occurring disease process. It is not the intent of any state to use these documents to assist a patient who has attempted to commit suicide. . . . Such a view would be considered violative of public policy." W. LeStrange and K. Porter, "Risk Management and Legal Principles," in Goldfrank's Toxicologic Emergencies, ed. L.R. Goldfrank et al. (New York, N.Y.: McGraw Hill, 2002), 1776 (italic added). I have not, however, been able to locate statutory evidence of this assertion.
6. "Physicians do not permit suicidal patients to refuse treatment, because most suicide attempts occur when judgment is impaired, and most suicidal patients have a reasonable chance for recovery." R.K. Wagle et al., "An Ethical Dilemma: When the Family Wants the Withdrawal of Care," Journal of Psychiatric Practice 10, no. 5 (September 2004): 335 (italic added).
7. A recent study found that only 22 percent of suicide attempters wished that their attempt had succeeded, while 36 percent wished they hadn't made the attempt and were glad to be alive. G. Henriques et al., "Suicide Attempters' Reaction to Survival as a Risk Factor for Eventual Suicide," American Journal of Psychiatry'162, no. 11 (November 2005): 2180-2.
8. Albeit under strictly controlled circumstances, including the documented absence of depression. Oregon Death with Dignity Act, Oregon Revised Statute 127.800-127.995, see http://egov.oregon.gov/DHS/ph/pas/docs/statute.pdf.
9. WISQARS (Web-based Injury Statistics Query and Reporting System, 2006), Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, www.cdc.gov/ncipc/wisqars, accessed 4 January 2007.
10. The condemnation of suicide can be based on philosophical (e.g., Plato, Aristotle) or theological (e.g., Augustine, Aquinas) grounds. While this is the prevailing viewpoint in our culture, there are well known arguments to the contrary. The Stoics emphasized quality of life over duration. Thus Seneca: "Mere living is not a good, but living well. Accordingly, the wise man will live as long as he ought, not as long as he can." L.A. Seneca, Moral Epistles, vol. 2, trans. R.M. Gummere (Cambridge, Mass.: Harvard University Press, 1917-25), 57. Aquinas's condemnation of suicide as a violation of natural, moral, and divine law was answered point by point by Hume. And perhaps most famously, Existentialism stresses the question of continued existence. Thus Camus: "There is but one truly serious philosophical problem, and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy." A. Camus, "The Myth of Sisyphus," in The Myth of Sisyphus and Other Essays (New York, N. Y.: Alfred A. Knopf, 1955), 3.
11. See note 4 above.
12. Or, at the very least, the chance to prove that they possess the ability to make such decisions, all a priori evidence to the contrary.
13. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Washington, D.C.: American Psychiatric Association, 2000).
14. See note 6 above.
15. Compare with K.A. Wilson et al., "Perception of Quality of Life by Patients, Partners and Treating Physicians," Quality of Life Research 9, no. 9 (November 2000): 1041-52.
16. D.I. Shalowitz, E. Garrett-Mayer, and D. Wendler, "The Accuracy of Surrogate Decision Makers: A Systematic Review," Archives of Internal Medicine 166, no. 5 (March 2006): 493-7.
17. T.C. Bania, R. Lee, and M. Clark, "Ethics Seminars: Health Care Proxies and Suicidal Patients," Academic Emergency Medicine 10, no. 1 (January 2003): 65-8 (italic added).
18. Assuming that this was a true suicide attempt rather than merely a suicidal gesture, and granting that this wish may not be deemed truly "autonomous."
19. Both poetically and epidemiologically, as Dorothy Parker wrote in her poem, "Resume," Razors pain you; Rivers are damp; Acids stain you; And drugs cause cramp; Guns aren't lawful; Nooses give; Gas smells awful; You might as well live. D. Parker, "Resume," in Enough Rope (New York: Boni and Liveright, 1926).
20. E.D. Shenassa, S.N. Catlin, and S.L. Buka, "Lethality of Firearms Relative to Other Suicide Methods: A Population Based Study," Journal of Epidemiology and Community Health 57, no. 2 (February 2003): 120-4.
21. National Center for Injury Prevention and Control, http://webappa.cdc. gov/sasweb/ncipc/leadcaus.html, accessed 9 December 2006.
22. G.J. Wintemute et al., "Mortality Among Recent Purchasers of Handguns," New England Journal of Medicine 341, no. 21 (November 1999): 1583-9.