3.3.2 Harm to Self
Mona Gupta, MD CM, FRCPC, MA
Updated December 23, 2013
- To consider one's ethical responsibilities in situations where a patient has threatened to harm, or has actually harmed him- or herself in the context of suffering from a mental disorder.
- To become aware of the relevant medico-legal mechanisms available when one encounters a patient who has threatened to harm or has harmed him- or herself in the context of suffering from a mental disorder.
Sarah is a 36-year-old woman who is employed as a grade 3 teacher. She is single and has no children. She is brought to the ER of a general hospital by her friend Diane. The triage nurse's notes state that the patient has no real chief complaint. However, Diane spoke to the triage nurse herself, saying that she believes Sarah is thinking of killing herself.
Both Sarah and Diane are seated in the examination room. Sarah is dressed shabbily in worn and lightly stained clothing. Her face is gaunt and pale. Her hair is messy. She looks at the physician when she enters, but does not speak. The physician introduces herself and Sarah says "Hi." When asked why she has come to the ER, she points to Diane and says, "It was her idea."
Diane tells the physician that she is a colleague of Sarah's. They are friends, but not close. It being the summer they are not seeing each other at work every day, but do get together every couple of weeks. Diane reports that Sarah has two brothers who live in other provinces. Her elderly parents are away on an extended trip. Sarah has a few other friends whom Diane does not know well.
Diane became concerned when Sarah stopped returning her calls and e-mails. Eventually she went to Sarah's apartment. Sarah let Diane inside, and Diane noticed that the blinds were drawn and the place was quite untidy. Diane asked Sarah what was going on and she said that she just wasn't feeling much like going out. Diane notes that Sarah is usually quite tidy and well-groomed. She is a quiet person, but is usually more talkative than she is at present.
Sarah told Diane that, over the last few weeks, she has only gone out to check on her parents' home. Diane offered to accompany her to her parents' home this week. While there, Sarah took a long trip to the washroom. When Diane went to check on her, she found Sarah examining the contents of her parents' medication cabinet closely. She said quietly, "I could just take all of these pills and end it now." Upon hearing this, Diane insisted on bringing Sarah to the ER.
When the physician tries to interview Sarah, she provides short and often uninformative answers. She describes her mood as "Ok." She says she has been eating less, but attributes this to the summer heat, which diminishes her appetite. She does not appear psychomotor retarded or agitated. She denies psychotic and manic symptoms. She becomes irritated when asked her about alcohol and substance use, saying, "It is considered healthy to drink a few glasses of wine each day." When asked how many glasses she drinks, she says three, sometimes four.
Sarah looks bored when asked other questions related to depression and responds by saying, "What do I have to say to get out of here?" The physician asks her directly whether she has plans to try to harm or kill herself. Sarah replies, "Well, who would miss me? No one but the cat." When Sarah is asked what kind of support she has in her life, she responds that she is a private person and usually keeps things to herself. She insists that she is not the kind of person who feels comfortable with "shrinks."
- Q1. What are the primary ethical considerations underlying the clinical approach to cases of actual or potential self-harm?
- Does Sarah have the right to refuse these interventions?
- Is Sarah's capacity to make treatment decisions relevant to decisions about intervening in situations of self-harm?
- What rights to confidentiality does an individual have if he or she has threatened to or has harmed him or herself?
The threat of or actual harm to oneself in the context of a mental disorder is a domain that is governed, in part, by legislation. Each province or territory has a law, usually called the Mental Health Act, that lays out criteria and procedures for hospitalizing someone when he or she has threatened to or has actually harmed him or herself, but is not willing to participate in psychiatric treatment. However, involuntary hospitalization is not the only way to approach this clinical situation. The clinical approach and management options in each individual case, will depend on the weighing of several ethical considerations. Cases of harm to self involve consideration of each of the classic principles of ethics: autonomy, beneficence, non-maleficence, and justice.
Even when physicians do draw upon mental health legislation to guide them in involuntarily hospitalizing patients who have harmed or threatened to harm themselves, there are many aspects of this clinical intervention that are not and cannot be specified in legislation. Clinical scenarios are too variable and often too complex to be fully codifiable. The questions that follow explore some of the key ethical aspects of the clinical approach to self harm, using the preceding case to provide illustrations.
While there are legal procedures in place for the involuntary admission of patients who are at risk of self-harm, these are always subject to interpretation at the clinical front line. A variety of clinical and ethical factors might be taken into consideration, including the patient's decision-making capacity, her diagnosis, her social situation, her past history and experience of psychiatric treatment and hospitalizations, the physician's understanding of his or her duties to patients, and the availability of resources including hospital beds. The manner in which physicians weigh up these individual factors may lead to very different decisions in apparently similar clinical cases. This does not pose an ethical problem, provided that physicians are aware of their legal responsibilities while at the same time, making explicit the various values or principles they have considered in deciding how to intervene. Involving the patient as much as possible, and other members of the healthcare team, helps to ensure that the LRA is chosen. If involuntary measures are necessary then they should be focused on the patient's best interests, avoidance of harm, and on making progress toward voluntary (autonomously chosen) interventions as quickly as possible.
- Beauchamp T.L. and Childress J.F. Principles of Biomedical Ethics 7th edn. Oxford: Oxford University Press;2012
- Chodoff P. Involuntary hospitalization of the mentally ill as a moral issue. In: Green SA and Bloch S,editors. An Anthology of Psychiatric Ethics. Oxford: Oxford University Press; 2006: pp. 192-195.
- Szasz T. The case against suicide prevention. In: Green SA and Bloch S, editors. An Anthology of Psychiatric Ethics. Oxford: Oxford University Press; 2006: pp.196-200.