Medical ethics of suicide

Gonzalo Herranz, department of Bioethics, Universidad de Navarra
outline from class
Murcia, 1996

In its original essay this text is not fully developed, but the part dedicated to the medical ethics of suicide care and suicide prevention is. We have not been able to find out which is the text of the first example given to the students for reflection. We make it available to the public because of the interest of both the schematic part and the ethical reflections.

Introduction: the dimensions of the problem

Suicide: topic on the rise.

Secularist ideology of man's lordship over his own life: as a background to the problematic right to kill oneself, to obtain medical financial aid for one's own death, to demand euthanasia.

In statistics, in social outreach (adolescents, unemployed, sick, elderly). grade of the BMJ (January 20, 1996, on suicide in men over 65 years of age in the USA: alarm). France, Japan, students, Holland, AIDS. 

Under public discussion (publication of Final Exit, financial aid legislation to suicide).

discussion on nature: rational, lucid suicide, as opposed to manifestation of illness, pathological autolysis, traditionally regretted.

Epidemiology. On how those around the suicide attempter should behave: cultural prevention, individual vigilance and control, financial aid to the parasuicidal, suicide prevention. Nature of mental illness, role of religion, medicine, family, society. Moral nature of suicide.

The eighth leading cause of death, with wide variations: 28 per 100,000 in Hungary, 12 per 100,000 in the USA, 9 per 100,000 in Spain, 3 per 100,000 in many Islamic countries. About 750000 suicides in the world per year.

Age ranges and socioeconomic classes. Male/female ratio: completed suicides 4/1. Suicide attempts 1/3. Elderly much more than the rest of the population: about 80/100000. Much variation

Scientific models

model medical: illness, a product of illness, almost always of mental illness. Something not deliberate, not voluntary, something that happens to the sick person. Psychic autopsy: depression or other mental disorders.

model of a cry for help. It is more valid for parasuicide, which tries to change the environment surrounding the suicidal person. The cry is directed at someone. In a certain sense it is manipulative, it does not look for death, but to call the attention, it tries to mobilize the family, the doctor, the community, so that they change the circumstances of a charged life. Suicide as a threat, as a currency to acquire advantages, as a gamble. A risky way of doing degree program.

model sociogenic. Product of social forces and circumstances. Suicidogenic environments, times of dissolution of family and social ties, or times of integration, crowding. Social fetishes: the Indian widow who immolates herself on the pyre of her deceased husband, the captain of the ship that sinks with him, the gambling debtor who cannot pay and does not want to be dishonored.

Complex issue.

3. Medical ethics issues

In the face of suicide, what are the physician's deontological obligations? Basically, two. The first is to care for the victim of an attempt at self-destruction. The other is to contribute to the prevention of suicide, to fight against this endemic evil in our society.

a. The obligation to attend medically the suicidal person.

The extremists of ethical autonomism claim that everyone, including the physician, must respect to the end the suicidal action of those who freely and consciously decide to do so and carry it out. They are convinced that every autonomous person has the right to commit suicide. And that, if the fulfillment of this decision does not affect the interests of others, no one is authorized to interfere in his or her action, neither to prevent it, nor, once it has begun, to stop its course.

Medical deontology, however, does not admit the physician's cooperation in suicide, nor does it admit neutrality or passivity in the face of it. The physician cannot cooperate, in the first place, in a lucidly calculated and programmed suicide. Such an act is result of an ideology, totally foreign to the medical ethos, which holds that man can freely dispose of his life and is graduate to choose the place, manner and time of death. The physician, who would be asked to financial aid for the execution of this cold-blooded suicide, could not cooperate, as a physician, to an act in which there is no disease status that calls for his specific professional intervention. Suicide is not the medical solution to any human problem, nor is it a human solution to any medical problem. "To no one, even if he should ask me, shall I give poison, nor shall I suggest to anyone to take it," says once and for all the Hippocratic Oath.

Moreover, when suicide seems to be the only possible way out in the face of a desperate status of pain or uselessness, suicide remains a non-solution, because the victim, in addition to annihilating his life and dignity, hurts and upsets those around him. Suicide triggers concentric circles of pain and feelings of guilt in those close to the victim and even in simple bystanders. For many people, the completed suicide leaves a deep and very lasting mark of torturing grief. In others, it shatters moral convictions in the face of self-destruction, which is sublimated, in the victim's gift, into something fallaciously dignified and honorable, and even heroic. It is precisely on such susceptible population where the hero acts as model and as a contagious germ, which initiates and spreads a microepidemic of mimetic suicides.

Therefore, the idea of "innocent" suicide is not admissible. Suicide always causes some harm to others: it always hurts a few people very badly; however elegant and clean it may be in its motives and execution, it involves a focal destruction of humanity and erodes respect for man in a diffuse but efficient way. All suicide is pathogenic: therefore, the physician can never ethically cooperate with voluntary suicide: neither in the induction, nor in the justification, nor in the financial aid.

There are those who do not think so. In a paradoxical article publishing house , published in a French journal, Michel Bénezech summarizes, after exposing the legal and deontological doctrine of the case, the attitude of the physician in this way: Even if one is legally free to commit homicide on one's own person, the physician who treats the one who has attempted suicide is not, in that circumstance, an impartial arbiter between life and death. The physician has no choice. He must always and in all circumstances take care, try to recover that life that escapes, preserve it, restore it. He must prevent the flickering flame of the lamp from being extinguished: this is his moral, deontological, management assistant (hospital liability) and criminal (risk of not attendance) obligation. And that, whatever the deadly will of the suicidal person who is dying.

It is necessary that each plays its role with clarity, without ambiguity, and is ready to effectively achieve its goal: the one to preserve life, the other to efficiently achieve its own death.

And he ends by illustrating his article with an example of macabre humor: Having decided that his time had come, the great Bordeaux painter Molinier, born in 1900, shot himself dead with a revolver on March 3, 1976. On the door of his apartment he had left an grade written in his own handwriting: "I have killed myself. The doorman has the key".

A terrible mistake. Suicide always hurts. Individually, it destroys a life. Socially, it acts as a poison. It is known to provoke, in predisposed people, a mimetic effect. An epidemiologic study of risk factors in two teenage suicide clusters (JAMA 1989;262:2687,2692). Increase in suicide by asphyxiation in New York City after the publication of Final Exit (NEJM 1993;329:1508-1510).

How should the physician behave towards the victim of attempted suicide? When someone decides to put an end to his or her existence, it in no way cancels the physician's moral obligations towards him or her: the self-inflicted wounds automatically make him or her a patient whose life must be rescued. Not intervening to respect the autonomy of the suicidal person denotes a lack of that sincere concern for others which is part of the medical vocation, whereas intervening to save a life is a medullarly medical action. That this is the truly deontological attitude is demonstrated by the repeated experience, quantitatively overwhelming, of the gratitude of the majority of suicides rescued from death thanks to medical intervention. The physician will always be right if he interprets suicide as the last and most heartbreaking request for help.

At summary: Deontology teaches that the physician cannot, under any circumstances, renounce his role as healer and protector of life. He cannot remain indifferent to the human being who, for whatever reason, is discussion between life and death. The good doctor has no escape: he must take care of the suicidal person as of any other patient in an emergency status , and he will try to prevent the self-annihilation that has begun from being consummated. He will act in this way not only to escape the criminal risks of denial of aid or omission of the duty to assist, but also to comply with the deontological rule of recovering the physical and psychological health of man. If the physician refrains from acting, people would have the right to suspect that sometimes the physician is sample indifferent to the fate of those who need his care. Therefore, the physician will perform his official document as a healer in a clear and unambiguous manner, even if he is faced with a patient who reattempts suicide for the umpteenth time. If there are medical reasons to believe that the patient's recovery is possible, the physician will apply the obligatory resuscitation and intensive care measures.

b. The physician in the fight against the suicidal endemic.

In a study on suicide in the world, January 1, 1994, from the BMJ, we read that Australia has the highest rate of youth suicide in the world. More Australians die from suicide than from traffic accidents. Australia has no coordinated prevention programs. It is in third place, after cardiovascular diseases and cancer, in the list of causes of death. And suicide "epidemics" have been traced there: the same reasons (leave for unemployment, school failure: to see that others rise, are esteemed and live like kings, and they are despised and failed), ways to execute it (hanging, carbon monoxide from exhaust pipes in garages, bridges that have had to be fenced to make it impossible to jump from them into the river).

As in any other medical status , relapse prevention is an essential part of the treatment. That is why,

There is a second important aspect of the medical ethics of suicide: the physician's obligation to reduce its incidence. He will do this first by preventing relapse into suicidal behavior in the patients he has cared for. His work does not end when he recovers his patient from the acute status and restores his homeostatic constants. He must also try to restore, if not joy, at least the courage to live.

attend The treatment of suicidal patients in the acute phase is relatively easy today, thanks to the implementation of highly qualified and technologically advanced intensive care and detoxification medicine. This requires, above all, monitoring of the patient's biochemical and functional parameters. Very often, however, the suicidal person wakes up unprotected, extremely lonely. As the patient regains awareness of his status and of his new recovered life, he needs with increasing intensity to be helped in his personal problems, he needs to be welcomed in the community of the living. And this is not easy. It demands from the physician a lot of skill and energy.

Deontology imposes on physicians, in addition to caring for their own patients, the duty to look after the health of the community. In his internship, the physician, whatever his specialization program, must be able to recognize or sense in time the risk of suicide. This is very unevenly distributed among the various medical specialties. Some, such as oncology and psychiatry, are particularly threatened by this danger. Leaving aside free will as the determining cause of suicide, there are medical factors (incurable disease, affective disorders, unbearable pain, uselessness, heredity and character) and social factors (loneliness, mimicry, life events, awareness of being despised, cruel treatment, involuntary confinement) that indicate situations of increased risk of suicide. The physician must know how to detect them in time and assume the responsibility to intervene in them. If he/she does not consider him/herself capable, he/she should ask for a colleague who can do it with financial aid skill . Each suicide among his patients is a call to examine the quality of preventive and curative care provided by the physician and perhaps an occasion to improve some aspect of it.

4. Two episodes. for analysis

The brother who committed suicide

From the bridge

Published in JAMA 1985;254:3314.

One very busy Saturday work, late one night, almost at midnight, during my placement in the emergency department, a young woman was brought in who had tried to commit suicide. She had cut her radial artery. We put a tourniquet on her, cannulated a vein, started her on saline and, as soon as we had her haematocrit, we transfused her blood. Once she was stabilised, the surgical resident came in and I helped her suture the separated ends of the artery.

I was devastated as I helped, because I could see the despondency and hopelessness on the face and in the eyes of that young woman. Every once in a while, she would burst into tears and say that life sucks, that it's not worth living. I imagined that she had had a bad heartbreak or something terrible, and that's why she had decided to end her life. The resident suddenly said to her: "Next time, why don't you jump on the train? And now stop whining, you're annoying me." When I heard that, I think I was as devastated or more than the patient: I couldn't open my mouth.

The resident finished the artery repair, which he did with great skill skill, and left without saying a word to the woman. I tried to console her, and also told her to understand, that the man was exhausted, that he had had too much work, and that he was like this because a patient had just died. But that he hadn't really meant what he said. She seemed to understand.

When I later told the resident about this, he told me that who was I to correct him, that he had believed me: that yes, he had said what he had said to purpose, and that he had no regrets. That there was no right for him to have to waste his talents on fixing people who were so busy ending their lives, and that he didn't even know how to do that well. He told me that it was a shame that there were people who felt desperate, who were floundering through life, and who saw death as the only escape from their problems. I could not move his convictions one iota. When, the next day, I discussed all this with the head of department, the incident did not seem to interest him in the least.

The resident violated the Hippocratic injunction that says first do no harm. But why did he do it? Is he so self-centered and insensitive that he doesn't give a damn about the suffering of others? Was he so exhausted and emotionally drained that the woman's crying finally got on his nerves? I don't know why he did it. Will I also be incapable of understanding pain like that woman's and offend my patients at purpose ?

This is the end of the story. The student of our story closes it with a series of questions. That is the essence of it. Therein lies the secret of ethical growth. He asked himself and, logically, we ask ourselves, why did the resident behave like that? What could his motives have been? And even more strongly, what did he do it for, with what purpose, what purpose did he seek? And who was the surgical resident: a racist, a subject possessed of his great importance, a petty philosopher of power, who despises the weak? Or simply, an element, much more wretched than the young woman, and victim of an unbearable inferiority complex, who covers himself with the shell of arrogance to hide and protect his weakness?

But the most serious part of the matter is that he did not regret doing what he did. This means that, in a similar status , he would act in the same way again. Why does a doctor who has made a mistake not want to repent of his error? How long does it take for one's conscience to become calloused and say that wrong is right? How long is it possible to go back and rectify? This is essential, because the mere fact of not recognizing mistakes predisposes us to continue making them.

But in the scene told, we cannot forget that it is not the Resident who is the main protagonist. It is the young woman. Hearing the story may not be enough. An ethical story requires getting into the scene, not reducing the characters to abstract, unreal entities, mere examples. In fact, this was a woman of flesh and blood, an unfortunate human being. It is necessary to make the effort to give her a face, to make her a real person: she could be a human ruin, a great person who has come to grief, destroyed by drugs. Or a poor unfortunate being, a victim of depression. She could be an AIDS patient, or an immigrant from the Dominican Republic, or a black woman, or, for that matter, a young doctor desperate because she had not passed the spanish medical residency program for the second time.

And the other protagonist is the Resident. We have already thought a little about him, but we must continue with the questions: what does it mean, for any doctor, to be tired after a whole shift full of emergencies and shocks? Are we not demanding a superhuman effort from a human being, a flesh and blood one too, someone who may be going through the humiliating crisis of not being as good as he thought he was, of being emotionally depressed because he has just lost a patient? And also, what is the part of the blame that, in his case, could be due to the poor organisation of the hospital, to the shortage of staff, to the fact that our lifestyle causes, at weekends, when it is most needed, a shortage of staff in hospitals and emergency departments? Many ethical resolutions can be deduced from such a case study, some of them impossible for the time being, such as reforming the emergency care system. Other solutions may be costly, such as regulating the maximum hours of work of the on-call resident. The conscientious physician does not leave for good once he has sutured the artery. He realises that it is just as urgent to help the woman overcome her life crisis and thus prevent a further suicide attempt.

Ethical analysis is always fruitful: the core topic is in asking questions and seeking answers. Concern for medical ethics makes us better.