This article appears in the May 2005 edition of the Catholic Medical Quarterly
Cooperation problems in care of suicidal patients
Helen Watt
As a general rule, the lives and health of adults are entrusted to their own care. The authority of healthworkers over adult patients is delegated by the patient. Healthworkers must respect the boundaries of their patients’ bodies both by refusing to intervene harmfully - especially where the harm is serious and permanent - and by refusing to intervene without consent except for good reasons. In other words, they must respect both the patient’s bodily flourishing and the patient’s prime responsibility for that bodily flourishing. That said, a choice of suicide causes such damage to the patient and to others that the threat of suicide dramatically changes the healthworker-patient relationship. This is so even when the suicidal person is thought to be fully competent, such that many choices by that person would have some claim to be respected.
1. Suicidal refusals
Suicide can, of course, be carried out by omission, as well as by an act. A patient who fears the extension of a life which is felt to be both painful and pointless may refuse treatment and/or care with the aim of accelerating death. Those around the patient, such as doctors and nurses, may realise themselves that the patient’s life has value - despite the patient’s current feelings - and may be unwilling to facilitate suicide, even unintentionally, by omitting treatment or care. In this paper, I will look at the responsibilities of healthworkers in this situation, and at what counts as "complicity" or wrongful cooperation with the patient’s plan. I will look, in particular, at cases where the patient also sees what he or she refuses as too burdensome, though this is not the patient’s only reason for refusing the procedure.
Of course, if a procedure really is too burdensome - either in itself, or in relation to the benefits it promises - that procedure should not be offered,especially to an unwilling patient. The burdens involved are a individual matter: a procedure which is genuinely too burdensome for one patient, due to his or her particular sensitivities, may not be too burdensome for another. Having said this, the benefits of a procedure also vary from patient to patient. Such benefits include social benefits - which would include giving patients who are suicidal and despairing the chance to reacquire a sense of the value of their lives. We should not too quickly give up on a patient’s ability to resolve conflicts and be reconciled with life, with other people and, indeed, with God, given time and support.
What I want to focus on initially are cases where procedures are unreasonably refused by the patient both on the grounds of their perceived burdens and with the aim of ending life. Even taking into account particular sensitivities, the burdens involved do not justify refusal; moreover, the patient is also clearly motivated by the aim of hastening death. There are four possible scenarios of this kind which I would like to explore.
2. Mixed motives
In the first scenario, the patient refusing the procedure is "strongly suicidal". That is, the suicidal motive would suffice to account for the refusal even without the patient’s other motive of avoiding the procedure itself. Moreover, the aim of avoiding the procedure is an "underdetermining" motive: were it not for the fact he wants to die – or at least, sees his life as worthless - the patient would not count the procedure’s burdens as a reason to refuse it. On the contrary, those burdens would have been accepted had the procedure promised what the patient saw as a life worth supporting. Perhaps the patient sees any procedure as involving burdens too great for its benefits if continued life is not seen by the patient as a benefit at all. Though only the background to a suicidal purpose, the view that life is not worthwhile is very closely linked to that purpose. For this reason, it should not be regarded as an independent reason for respecting refusals that are also suicidal.
There are three possible variations on the scenario just outlined. In the second scenario, the patient is also strongly suicidal, but is, in addition, strongly set on avoiding the procedure itself. Either of these motives would alone be sufficient to account for the patient’s refusal, though in the event, the patient is refusing on the basis of both combined. In the third scenario, the patient is weakly (or more weakly) suicidal: only in conjunction with the strong motive of avoiding the unwanted procedure does the weaker motive of shortening life come into play. In the fourth scenario, the patient is weakly suicidal, and also weakly motivated by the aim of avoiding the unwanted procedure. Only in combination do the two desires - the desire to die, and to avoid the burdens of the procedure - give rise to intentions, and to subsequent behaviour. Neither the wish to die nor the wish to avoid the minor burdens of treatment or care would suffice on its own, though they suffice in combination to form the intentions which ground the refusal. The two motives are jointly determining, but separately underdetermining. (Perhaps I should say here that in referring to determining motives, I am not denying free will. Rather, I am simply referring to the "strength" or explanatory power in various situations of the motives of someone who may have been fully free to make a different choice.)
It may be objected that my four scenarios are, in fact, unrealistic. Surely those who are truly suicidal, or truly anxious to avoid a certain procedure, will have that and that alone as an explanation of their behaviour? However, it is often the case that we do, or refrain from doing, something with two independent motives, each of which may be over- or under-determining of our decision when we act. For example, I may decide not to go to Bali both because I dislike Bali and because I find the journey burdensome. In the same way, a patient may recoil both from the burdens of treatment and from what the treatment will achieve: an extension of life. Such recoiling may give rise to mutually reinforcing aims: the aim of avoiding the burdens of treatment, and the aim of hastening death.
The scenario in which one intention is over- and the other intention under-determining also accords with our experience. The fact that one intention is doing more work than the other need not reduce the other to mere foresight of a (welcome) result. Admittedly, the bigger the distance between the strength of the motives - the work they are doing in explaining one’s behaviour - the more likely it is that one motive will take over, and the other will cease to be considered. However, a motive which is insufficient to account for our choices by itself may still be a bona fide motive, existing side-by-side with what we otherwise intend. Thus a patient may be strongly suicidal, and less strongly set on avoiding the burdens of treatment (we can imagine that he would accept those burdens if the life which the treatment would extend were even slightly beneficial in his eyes.) Alternatively, the patient may be strongly set on avoiding the burdens of a certain procedure, and aiming at his own death only as a secondary intention. Perhaps the patient has a moral objection to suicide, and wrongly believes he is justified in aiming at death providing he is also aiming at avoiding a burdensome procedure. (I am not, of course, making a judgement about the culpability of such a person, who may be making what I see as a moral mistake through no fault of his own.)
3. Conclusive motives
How, then, is the health professional to act amid these possible scenarios? I would argue that a weak, undetermining suicidal motive may often be set to one side in responding to refusals of some procedure, in the presence of a much stronger motive of avoiding the procedure itself. Only if the suicidal motive has some visible, outward effect (that is, if it determines the refusal, alone or in conjunction with some other motive) will there be a particularly strong reason to override the refusal. However, in cases where the life-avoiding motive is both weak and inconclusive, doctors and nurses should still make it clear that they themselves are not intending death. "That’s not why we’re stopping treatment", the doctor might say. "We don’t want you to die, we just don’t want to give you treatment you feel you can’t cope with." (Of course, if the patient has, as we are imagining, an exaggerated view of the treatment’s burdens, the doctor should first make a reasonable effort to persuade the patient to accept it.)
How should the doctor or nurse respond if the patient’s suicidal motive is sufficient - or at least conclusive - in accounting for his or her refusal? In this case, the healthworker should, prima facie, override the patient’s refusal - always assuming the procedure’s burdens are not objectively too great. A few simple questions to the patient should throw some light on his or her motives, providing the patient is willing and able to respond. For example, "Is it mostly that you don’t like the treatment, or mostly that you want to die?" "Would you still say you didn’t want that treatment if you didn’t want to die?" There is – at very least - a strong presumption in favour of preventing suicide: a choice particularly harmful to the patient, to those about him or her and to society at large. It is important to give suicidal, and especially strongly suicidal, people the message that others are trying to help them, and will not give up trying simply because they say no. There should be a policy of treating patients with conclusive suicidal motives in their best interests, just as we treat, or should treat, patients who are non-competent in their best interests. (It may, however, be the case that some procedures practically require the compliance of the patient. In what I say here, I am assuming that overriding the refusal will be feasible, bearing in mind the healthworker’s other commitments.)
It may be asked why it should be so important to determine if the suicidal motive in the patient is strong and/or conclusive. Morally, there is some significance to the fact that the will to end one’s life is strongly held. An intention that is morally wrong does more moral harm to a person the more firmly rooted it is in the person’s psyche, such that it would be likely to be retained (at least in the short term) even without a second motive. However, perhaps moral harm per se is not the central issue here. Intentions which have visible causal effects (apart from their sheer presence being detected or reported) are arguably more in the public domain - more the business of others - than intentions which do not have such effects. Of course, in the term "visible causal effects" I am including the effects of omissions, where the wrongful intention was significant for subsequent events.
4. Legal/professional pressures
What are some other factors that might influence the doctor or nurse’s response? Here I will look at various factors which might be morally relevant, whether or not the suicidal patient has a second aim in his or her refusal. The first factor is legal or professional pressure: doctors, for example, may fear repercussions if they fail to comply with suicidal refusals, or pass the patient to a colleague who will do so. What should a doctor do when expected either to respect the patient’s wishes - suicidally motivated or otherwise - or pass the patient to a colleague with fewer qualms? What kind of risk of legal or professional penalties should a doctor be prepared to accept? The pro-life doctor may, of course, argue that suicidal refusals and/or cooperation with such refusals are, in fact, unlawful. However, this defence will not be open to doctors in all legislatures: deliberate assistance in suicide by omission may well be legally permitted in the place in which the doctor works.
Positive duties - that is, duties to make (as opposed to avoiding) certain choices - are not normally absolute. It is negative duties, such as the duty not to choose death by act or omission - leaving aside the requirements of justice - which bind absolutely. If a relative pointed a gun at a nurse’s head and told her not to feed a suicidal patient, the nurse would surely be entitled to omit the choice to feed. Of course, the penalty, if one exists, for intervening to prevent suicide would normally be much less certain, and much less severe. Moreover, we can imagine particular circumstances which would mean a higher risk of repercussions should be taken by the health professional. It might be argued that a higher risk should be taken in the case of patients who are now incompetent (we can think, for example, of those who have signed advance directives with a suicidal motive). Such patients seem more completely and permanently entrusted to the healthworker’s care than do competent patients who are actively seeking to prevent their lives being saved. In view of this, withholding treatment or care from an incompetent patient may be difficult to justify, and may encourage similar neglect of other incapacitated people. This applies particularly to the withholding of food and fluids, which is particularly likely to be seen by others as deliberate killing of the patient, even if the healthworker does not, in fact, have this aim.
On the other hand, there are factors which could make withholding treatment or care from a currently suicidal patient difficult to justify. Cooperation in an ongoing - and therefore in a future - suicidal plan seems in itself more serious than cooperation in a plan formed in the past by a patient who is now incompetent. In addition to the ongoing moral harm involved in the patient’s current suicidal plan, there is a benefit available only to patients who are competent: the benefit of reassessing the value of one’s life and/or the burdens of what one is refusing. If this benefit seems at all achievable, again, it is possible that higher legal/professional risks should be taken by the health professional.
5. Referral
Difficult questions are also raised by the issue of referral. The General Medical Council (GMC) allows a doctor who is unhappy with a patient’s refusal of life-prolonging treatment - including tube-feeding - to withdraw from that patient’s care. However, the GMC also requires that senior doctors in this situation ensure "that arrangements have been made for another suitably qualified colleague to take over their role, so that the patient’s care does not suffer". While the GMC does not, on the face of it, require that the doctor referred-to take a different view from the doctor who refers, this may nonetheless be a foreseeable result of referring the patient to a colleague. The colleague may be indifferent to, or even disapproving of, the patient’s wish to die, but may nonetheless think him or herself obliged to respect the patient’s refusal. May a pro-life doctor refer to such a doctor, in the limited sense of transferring the patient to him or her? I would say yes, at least in some cases: it is neither formal nor very close material cooperation to refer to a doctor one knows will fail to prevent suicide, if one is not referring for that reason, and is under serious pressure to refer. Such an action is more like what a doctor does when going off duty: the doctor passes patients to the care of others without necessarily endorsing how those others will behave. However, if, in withdrawing from a patient’s care, one passes the patient oneself to another doctor it is important not to give the impression that the doctor is chosen as someone with different moral views from one’s own. On the contrary, one would gladly refer to a pro-life colleague if such a colleague was available. Of course, there will sometimes be an overriding reason not to refer to a non-pro-life colleague: for example, to a doctor who is strongly pro-suicide, rather than simply unprepared to override a suicidal refusal.
6. Active interventions
There is another factor which can influence the doctor’s responsibilities. Doctors may rightly be unwilling to cooperate with a strongly suicidal patient if such cooperation involves an active intervention which itself causes harm. For example, the doctor may be unwilling to turn off a respirator at the request of such a patient. In cases where harm is not intended, but will nonetheless occur, there is a special onus on the doctor not to cause harm by an active intervention. While it is not reasonable, in view of competing opportunities to do good, to expect that people always intervene to prevent harm, there is more of a presumption against intervention where this itself does only serious harm, even if the harm is not intended. Assuming there is no other reason for turning off the respirator than the patient’s suicidal request, it is, I would argue, wrong for the doctor to accede to this request, even under threat of disciplinary action. Admittedly, such an act is a "prevention of a prevention" - i.e. it merely reverses the effect of a previous intervention to sustain life. In this way, it differs from the sheer initiation of a causal chain leading to death. Nonetheless, in one respect, such an act involves closer complicity in suicide than failing to treat - or even supplying dangerous drugs - in that the act itself is one which leads inexorably to death. While even closer complicity can be envisaged - such as injecting, under threat, a lethal substance into the patient - an active intervention which itself causes death in a strongly suicidal person is something the doctor should avoid, even at the risk of serious repercussions. Again, some forms of active, non-intentional cooperation with a suicidal refusal will be more scandalous than others: more likely to be interpreted as euthanasia or assisted suicide, or at least as agreement with a policy of neglect. An example might be the removal of a feeding tube from a patient who had made a prior, suicidally-motivated request that this be done.
7. Conclusion
Sadly, such situations are likely to become more common in the future, with the spread of the concept of the "worthless" life, in combination with an exaggerated stress on patient autonomy. In particular, with the passing of the Mental Capacity Act in Britain, there will be many such dilemmas of conscience for doctors, nurses and others. It is unclear whether (for example) the GMC will sufficiently respect conscientious objection, though human rights law on respect for freedom of religion can also be invoked. Health professionals have a special responsibility to protect their patients from harm, and their profession from a growing disregard for human life and health. Courage, prudence and prayerful reflection will certainly be needed, in years to come, by those with suicidal patients in their care.
Dr Helen Watt is Director of the Linacre Centre for Healthcare Ethics in
London.
This paper is also published in H.Watt (ed) Cooperation, Complicity and
Conscience: Problems in healthcare, science, law and public policy (London:
The Linacre Centre 2005).