In mental health practice, no explicit provisions have been made for existing law and codes of ethics to protect freedom and confidences of clients who, due to serious, irremediable, physical illness, rationally desire to end their lives. This paper makes a case for permitting suicide in these special circumstances. Starting with an analysis of permitted suicide, the legal background for applying this concept is provided, and ten model rules for permitting suicide in mental health practice are developed.
Physician assisted suicide has recently gained some legitimacy within the medical and mental health communities as a possible option for persons suffering from diseases such as Lou Gerhigs, multiple sclerosis, cancer, and HIV (American Counseling Association [ACA], Association for Gay, Lesbian and Bisexual Issues in Counseling, Coalition of Mental Health Professionals, Washington State Psychological Association, 1996; National Association of Social Workers [NASW], 1994; Oregon Death with Dignity Act, 1999; Slome, Mitchell, Charlebois, Benevedes, & Abrams, 1997; Werth, 1996). Nevertheless, contrary to recent correlation studies (ACA et al., 1996), standards of mental health practice invariably treat all suicides as products of mental illness, requiring paternalistic interventions such as incarceration or detention.
The counseling environment is presumed to offer prospective clients who have a need to work through problems of living, and of dying, a safe haven in which to do so. Unfortunately, for clients who suffer from severe irremediable medical conditions, which lead them to contemplate suicide, counseling portends risks of personal freedom and dignity. Counselors should be free to provide a conciliatory atmosphere in which to carefully work through end-of-life decisions, and clients should not be dissuaded from enlisting their services (ACA et al., 1996; NASW, 1994; Battin, 1991).
The idea of counselors permitting suicide of a client rather than intervening to prevent it may seem to fly in the face of conventional mental health wisdom. Nevertheless, an unqualified standard of intervention fails to accommodate the special circumstances of some clients whose contemplation of suicide is rational and is, therefore, not the result of cognitive dysfunction or mental defect.
This article introduces and defines the concept of permitted suicide. Second, it discusses the legal context for applying this concept to cases of rational clients who seek suicide as relief from the suffering and indignity of serious, irremediable physical conditions. Third, it considers the concept of rational suicide and applies it toward construction of standards for permitting suicide. Last, ten model rules for permitting suicide in mental health practice are proposed in light of the emerging analysis.
THE CONCEPT OF PERMITTED SUICIDE
Following is articulation of the (necessary and sufficient) conditions under which a mental health provider can be said to have permitted the suicide of a client:
A mental health provider (P) permitted a client (C) to commit suicide when (1) C successfully attempted suicide; (2) P reasonably anticipated that C would attempt suicide; (3) P was aware of at least one accessible intervention that could have thwarted C's anticipated suicide attempt; (4) P intentionally elected not to employ any such intervention; and (5) the proximate cause of C's death was C's lethal act.
The above conditions define permitted suicide in terms of the intentional omission of a preemptive suicide intervention. For purposes of these conditions, the variable P refers to any individual or institutional mental health provider having a legal duty of due care to its clients. This includes counselors as well as other mental health professionals such as social workers, psychologists, psychiatrists, and psychiatric nurses. P also includes any mental health facility such as a mental health agency or a psychiatric hospital. …