Ethical Aspects of the Prevention of Suicide in Psychiatry
Liégeois, Axel, Eneman, Marc, Ethical Human Psychology and Psychiatry
From an ethical perspective, three values are at stake in the prevention of suicide-the inviolability of life, the autonomy of the client, and the care relationship between caregivers and client. These values can be integrated in the following way. The best prevention consists of a good care relationship involving intensive counseling of the client regarding existential questions. In this way, caregivers can increase the client's autonomy and responsibility. Sometimes, however, caregivers need to intervene with protective measures to safeguard the inviolability of the client's life. Caregivers strive for a reasonable balance between autonomy and inviolability by means of the integrating value of the relationship.
Keywords: ethics; suicide; prevention; psychiatry
Suicide is one of the more important causes of death in our society and is often linked with a mental disorder (American Psychiatric Association, 2003; De Leo, Bille- Brahe, Kerhof, & Schmidtke, 2004; Hawton & van Heeringen, 2000; Maris, Berman, & Silverman, 2000). Caregivers in psychiatric services are regularly confronted with clients who want to commit suicide or attempt to do so. The rule of thumb is that caregivers try to prevent this from happening. In specific situations, caregivers often question this rule. This brings us to the following research question: How can caregivers provide ethically appropriate care to prevent suicide? The aim of this article is not to discuss the prevention of suicide as such but to develop an ethical view of the prevention of suicide in psychiatry.
To answer this question, we refer to the ethical advice given by an ethics committee for mental health care of a Belgian network of 13 psychiatric services administered by the Brothers of Charity (Liégeois & Eneman, 2009). Although this ethics committee has a local authority, it has expert knowledge in the particular field of psychiatry and its advices might have a broader interest. The ethics committee comprised 25 experienced caregivers, representing the various professional groups within mental health care and the 13 psychiatric services of the network. The members opted for a methodological approach that combined ethical discussion with the study of recent literature-the moral intuitions and practices of the participants were mutually confronted with insights provided by several scientific publications.
In the first instance, the moral intuitions and good practices of the members were shared within the group and inventoried. These intuitions and practices were clarified and critically evaluated by contrasting them with one another.
Then, the authors compared the results of the ethical discussion with insights found in literature. The authors did a search in PubMed with the keywords "suicide" and " prevention" and "ethics" and "psychiatry." Of the 69 results, eight articles were selected after examining the correspondence between the content and the keywords (Bell, 1999; Bron, 1986; Coverdale, Roberts, & Louie, 2007; Hewitt & Edwards, 2006; King & Cramer, 2008; Maltsberger, 1994; Rosenbluth, Kleinman, & Lowy, 1995; Sartorius, 1983). Many articles were dropped out because they had not a real ethical focus, which means dealing with moral values, norms, or principles. One article in a scientific reader was added to the literature (Heyd & Bloch, 1999).
Consequently, the authors put together a draftadvice that consisted of a synthesis of the ethical discussion and the literature research. The committee discussed the text and introduced several emendations. The draftadvice was emended until the committee members were able to reach consensus. The entire process took place within a forum that was open and free, thus allowing each participant to speak his or her mind without any form of pressure based on authority or function.
In this article, we develop the ethical advice. It contains the opinions that were shared in the ethics committee, based on ethical discussion and study of literature. …