Ethical Consideration in Dealing With Suicide in Different Populations

1.1. What should Dr. S do at this point?

1.2. What should Dr. S do next?

1.3. What are some other interventions that could have been implemented under the circumstances?

2.1. Which of the following is part of informed consent regarding medication use in pregnancy?

2.2. Should Dr. S call child protective services (CPS)?

2.3. What should Dr. S do at this point?

1.1. The answer is E. Dr. S should explore the least restrictive method to ensure safety and balance the principles of beneficence and nonmaleficence on one hand and autonomy and justice on the other. Mr. M has several risk factors for suicide and is reporting active suicidal ideation. However, he also has protective factors: He has a lack of intent to act on his thoughts, is hopeful, demonstrates future-oriented thinking, and is actively engaged in treatment. Although his risk for suicide is elevated, he does not pose a significant and imminent risk of harm to himself. Hence, hospitalization would be too restrictive. Dr. S and Mr. M should work on other nonrestrictive methods to mitigate the risk of suicide. Lethal means reduction is an evidence-based suicide prevention method that involves putting time and distance between the potential means identified to attempt suicide (6–8). A safety plan is a brief crisis intervention that includes lethal means reduction and other strategies, including identifying individual warning signs and triggers; internal coping skills to manage distress; and social supports and emergency contacts, including friends and family, clinicians, and emergency services (9, 10). Suicide safety contracts (or no-harm contracts) have been shown to have limited evidence for effectiveness and do not protect the physician from liability (11, 12). They should not take the place of appropriate suicide risk interventions.

1.2. The answer is A. The challenge here is to balance protecting the patient’s life and safety according to the principle of beneficence with safeguarding the patient’s autonomy over his body and the care that he is receiving. A pickup order and subsequent involuntary psychiatric hospitalization would be the appropriate action per the ethical principle of beneficence but would overrule the patient’s autonomy. At this point, it would be reasonable for Dr. S to consider that Mr. M is an imminent threat to himself, given several dynamic risk factors such as increased substance use, worsening depression, hopelessness, anxiety, insomnia, terminal medical illness, and the occurrence of a self-identified foreseeable factor that can put him in crisis.

An important clinical pearl to be considered is that up to two-thirds of patients who attempted suicide denied suicidal ideations, and one-half of these patients died by suicide within 2 days of the denial (13). This study also makes the argument that relying solely on verbalized suicidal ideations as a gateway for a more comprehensive suicide risk assessment is not adequate. “Foreseeable changes are events or stressors, which, if they occurred, could reasonably be expected to increase or decrease risk of suicide” (14). Early discussion and identification of risk and protective factors, and of foreseeable changes, can help clinicians remain vigilant about changes in dynamic factors. Dr. S notes that the two foreseeable changes that Mr. M identified have been met, which further confirms her assessment. Arranging for a welfare check is not adequate because of the risk level. Similarly, waiting for the next appointment, although ensuring autonomy, is not adequate considering the imminent risk.

1.3. The answer is E. Coordination between the emergency room and the outpatient psychiatrist would have provided a more complete picture of the circumstances and highlighted the imminent risk. Without this information, the emergency room psychiatrist’s decision was based on Mr. M’s denial of worsening psychiatric symptoms, suicidal ideations, and intent. A second option is a brief safety plan intervention (SPI) in the emergency room, with subsequent follow-up contact by telephone. A comparative study showed that this combined intervention reduced suicidal behavior in the postdischarge period by 45%, and there was an increased engagement in aftercare. Structured follow-up telephone calls include a brief check-in with regard to suicide risk and mood, revision of the SPI if required, and facilitation of engagement in aftercare (10). This scenario also highlights that the risk of suicide is the highest in the postdischarge period, particularly within the first 3 months (15).

2.1. The answer is E. A complete informed consent should have “disclosure, comprehension, voluntary choice, and authorization” (16). Disclosure would include informing Ms. C of the risks and benefits of both the proposed treatment as well as the alternative treatments and the option of declining treatment. Comprehension involves evaluating whether Ms. C understands the nature and severity of her condition. Voluntary choice and authorization are determined by Ms. C being able to make a consistent decision that she can express and ensuring that she is not under any coercion. It is important that Ms. C recognizes the consequences of untreated perinatal mood and anxiety disorders for both her and her fetus, as well as the increased vulnerability to suicide, particularly because of her past history of a suicide attempt in the postpartum period. During this period, it is also often helpful to engage support systems, including significant others.

2.2. The answer is B. Because there are significant concerns for neglect with Ms. C forgetting to feed and clean her baby, Dr. S should inform CPS. The ethical principles that Dr. S is adhering to here are beneficence and justice to the baby, which takes precedence over the mother’s autonomy, nonmaleficence, and confidentiality. Physicians treating young parents dealing with peripartum or other psychiatric illnesses have an additional responsibility for the child’s safety and welfare. Physicians are mandated reporters and have a legal and ethical obligation to report cases of suspected abuse and neglect. Reporters often struggle with the decision, worried that this may affect their relationship with the patient (nonmaleficence) and concerned about breach of confidentiality; separation of the child from the family, which may worsen the patient’s mental state (nonmaleficence); and the credibility of their suspicion. In an overwhelming majority of cases, reunification or keeping the child with the parent is the goal for CPS. CPS often provides services to support the parent’s ability to provide for their child’s health and safety (17). A majority of mothers, more than 70%, report intrusive thoughts related to infant harm (18), and initial data show that this does not correlate with actual infant harming behaviors (18, 19). Because Ms. C is clearly able to verbalize that she does not intend to harm her baby and that she is distressed by these thoughts, it does not qualify as a reason to call CPS. Dr. S has valid concerns here regarding child neglect, and that overrides concerns of how a CPS call would affect the mother.

2.3. The answer is E. Ms. C is reporting worsening symptoms of both depression and emerging psychosis, which place her at imminent risk of suicide. Ms. C has some other relevant factors that are associated with a high risk of perinatal suicide, including younger age, being single, having preexisting and current mental illness, intimate partner violence, poor social support, and psychological problems related to pregnancy complications (20). Her current presentation also warrants consideration of psychiatric hospitalization. Dr. S and Ms. C recognize the need for hospitalization, thus averting the need for an involuntary hospitalization. However, they are now faced with the dilemma of placing the baby in someone else’s care. Ms. C notes that she can call the baby’s father; together, Dr. S and Ms. C place the call. They also call CPS and inform them of the situation. Emergent psychosis in the postpartum period is a medical emergency that can change rapidly and increase the risk of harm to the baby as well, and it is ideally treated in an inpatient setting (21–23).